New Client Registration Form

New Client Registration Form

Please fill out this form to register as a new client. Your information will help us provide you with the best care.
How did you hear about AARC?*

Online searchPsychology TodayFrom my insuranceFrom a friend/family memberFrom other medical providerOther
Personal Information:
Full Name of person to receive services*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Spouse/Partner Name (if couples counseling)

First NameLast Name
Parent/Guardian Name (if applicable)

First NameLast Name
Insurance:
Insurance Provider (type n/a if not using insurance)*
Policy Number (type n/a if not using insurance)*
Group number (if applicable)
Name of Primary Insured (if not yourself)

First NameLast Name
Date of Birth of Primary Insured (if not yourself)

MonthDayYear
Date
Please list any secondary insurance (if applicable)
Upload front and back of insurance card

Cancelof
Contacts:
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship to you (client)*
Preferences:
Method of contact (select all that apply)

PhoneTextEmail
Preferred Therapist name (if known)
Consent:
Text Messaging: I understand that texting may not be HIPAA compliant or the most secure form of communication. Do you consent to receive text messages?*

Yes, I would like to receive text messages.No, I do not wish to receive text messages.
More Information about Protected Health Information (PHI)
Client/Guardian Signature*

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New Client Registration Form

Personal Information:

Insurance:

Contacts:

Preferences:

Consent: