CENTER REGISTRATION FORM

CENTER REGISTRATION FORM

[Please complete this entire form.]
Today's Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast NameSuffix
Address*

Full street address

Street Address Line 2

City/TownState

Zip
Phone (Home)
Please enter a valid phone number.
Phone (Cell)*
Please enter a valid phone number.
Phone (Work)
Please enter a valid phone number.
Email address*
example@example.com
Date of Birth*

MonthDayYear
Date
Age*
Height
Weight
Marital Status*
Highest level of education completed*
Your occupation*
Business Name / Address
Spouse's age
Spouse's Name

First NameLast Name
Spouse's occupation
Spouses' business name
Spouses' business phone
Please enter a valid phone number.
Spouses' business address
In an emergency, please contact*
Relationship*
Phone*
Please enter a valid phone number.
Child Name 1
Name and age
Child Name 2
Name and age
Child Name 3
Name and age
Child Name 4
Name and age
Other Relative 1
Name, age and relation
Other Relative 2
Name, age and relation
Other Relative 3
Name, age and relation
Other Relative 4
Name, age and relation
Primary Physician's Name*
Primary Physician's Address and Telephone Number*
Can we contact?*
Other Physician/Health Professionals, Address and Telephone Number
Other Physician/Health Professionals, Address and Telephone Number
Other Physician/Health Professionals, Address and Telephone Number
Whom may we thank for referring you?*
If not referred, where did you hear about us?
Briefly describe your reason for coming to see us:*
How long have these problems been bothering you?*
Describe your physical condition:*
List any major health problems for which you currently receive treatment:*
Please indicate any medications you are taking:*
1. These are the reasons why I have come to the Coping Counselors (check ALL that apply, and then explain in the appropriate box below):*

a. Cope with a medical problem (which problem?)b. Deal with a family problem (what problem?)c. Improve a relationship (with whom?)d. Resolve a work-related problem (which problem?)e. Deal with the loss of a loved one (who?)f. Deal with an emotion (e.g. depression, shyness, etc) (which?)g. Other specific reason(s) (which?)Not sure
a.
b.
c.
d.
e.
f.
g.
2- Please check any of the following areas which are problems for you:*

nervousnessguiltangerlonelinessdepressionshynessstressfearsunhappinessnegative thoughtsanxiousnessworthlessnesspanic attackshyperactivityobsession/compulsionsuicidal thoughtsboredomgriefphobia (specify below)
marital problemsseparationsexual problemsproblem with childrensocializationdivorcefriendsrelationshipsdeath of a loved onefamily problemsself esteeminferiority feelings
headachespainsmokingmaking decisionsdrug/alcohol usememoryconcentrationmedication (specify below)insomniafatiguehealth problems (specify below)weight/eating disorderself-controlwork-relatedschool relatedOther:
3 - I think I would prefer to work with:*

A female professionalA male professionalNot sure - either female or male professionalA specific Coping Counselor
If a specific Coping Counselor, please indicate name:
4 - Have you ever seen a psychologist/psychiatrist/social worker/mental health counselor before?*

YesNo
If yes, please describe.
5 - Please add any additional information which you feel may be useful.
By typing in your Full Name below, you are indicating your agreement to the following:
- I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered.
- I know that there will be a session charge for any sessions cancelled less than 24 hours prior to scheduled time, or broken without notice.
- Under HIPAA regulations, I acknowledge that all communications regarding my treatment will be confidential. I also acknowledge that you may contact me at any telephone numbers listed on this form, and in writing at home, and by e-mail, unless I instruct you otherwise, and that you may confidentially contact any professionals whose names are checked on this form.
- I have read all the information on this form and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you immediately of any changes in my health status, my insurance status, or any of the above information.
Full Name*
Date

MonthDayYear
Date
PAYMENT INFORMATION

(Exact fee and payment plan to be determined after this session)
Please check all that apply:*

I will pay in full at the time of each sessionI would like my insurance benefits to provide partial payment (Please fill out Insurance Information below)I would like information about your deferred payment plans
If will pay in full: indicate if by cash, check or credit card

cashcheckcredit card
Who is financially responsible for this bill?*
Please add any additional payment information which you feel may be helpful:
Insurance Information

(For out-of-network benefits)
I am covered by:*

Private insurance companyMedicareNo faultWorker's CompOther
Insurance company:
ID #:
Group #:
Insured's name:

First NameLast Name
D/o/b:

MonthDayYear
Date
Insurance company telephone number to verify coverage
Insurance company billing address:
Address

Full Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have secondary insurance? If so, company:
Additional insurance information:
THANK YOU FOR COMPLETING THIS REGISTRATION PACKET. WELCOME!!!
Should be Empty: