Client Registration Form For Substance Use And Mental Health Treatment Services

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Client Registration Form For Substance Use And Mental Health Treatment Services

Please fill out this form if you would like to register for substance use and/or mental health treatment services from SCAN.
Date of Registration:

MonthDayYear
Date
Services you believe you may need (check all that apply):

Other (please specify):
Presenting Problem: Below please describe in as much detail the reason you want to register for substance use and/or mental health treatment services, including the problems or needs you have.

Personal Details
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Sex:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone:
Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact
Full Name

First NameLast Name
Relation to you:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone:
Please enter a valid phone number.Format: (000) 000-0000.

Insurance Details
Do you have insurance?
Insurance Name:
Name of Insured:
Subscriber Number:
Relation to Insured:
Group Name:
Group Number:

Employer
Are you employed?
What is the name of your employer?
Address

Street Address

Street Address Line 2

CityState

Zip Code
Should be Empty: