EJC Pre-Registration/Referral Form

Emerging Journeys Pre-Registration Form
Location*

MinnesotaMichigan
Is this a Referral?*

Yes (Agency or organization)No, (new Client, spouse or parent of new client)
Name of person giving referral

First NameLast Name
Email of person giving referral
example@example.com
Phone number of person giving referral
Please enter a valid phone number.
Client Type*

AdultMinorCouple
Programs*

Therapy - AdultTherapy - MinorTherapy - Couples (Relationship)Adult Rehabilitative Mental Health Services (ARMHS)Case ManagementOther
Client Name*

First NameLast Name
Client Birth Date *

MonthDayYear
Date
Preferred Name
Client Email
example@example.com
Client Phone Number
Please enter a valid phone number.
Client Mobile Number
Please enter a valid phone number.
By entering your phone number, you agree to receive informational SMS messages (appointment reminders, account notifications, etc.) from us. Message frequency varies. Message and data rates may apply. for help, reply HELP or email us at (company general email address). You can opt out at any time by replying STOP. Our terms and conditions and privacy policy are below."
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Information
Parent Name*

First NameLast Name
Parent Email
example@example.com
Parent Phone Number
Please enter a valid phone number.
Parent Mobile Number
Please enter a valid phone number.
By entering your phone number, you agree to receive informational SMS messages (appointment reminders, account notifications, etc.) from us. Message frequency varies. Message and data rates may apply. for help, reply HELP or email us at (company general email address). You can opt out at any time by replying STOP. Our terms and conditions and privacy policy are below."
Parent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client #2
Client #2 Name*

First NameLast Name
Client #2 Phone Number
Please enter a valid phone number.
Client #2 Email
example@example.com
Client #2 Birth Date*

MonthDayYear
Date
Client #2 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Provider
Preferred Provider - 1st Choice
Preferred Provider - 2nd Choice
Appointment Information
Best Day of Week for Appointment
Best Times for Appointments
ARMHS
Client goal areas:

MedicalEmploymentFinancialDentalEducationSocial SkillsChemical UseHousingIndependent living SkillsOther
Primary Insurance
Insurance Type*

InsuranceSelf PayThird Party
Full Name*

First NameLast Name
Primary Insurance
Policy #
Group #
Member/Subscriber #
File Upload (Click to take picture. Upload picture of all insurance cards front and back)

Cancelof
Notes
Should be Empty:

Emerging Journeys Pre-Registration Form

Parent Information

Client #2

Preferred Provider

Appointment Information

ARMHS

Primary Insurance