Client Status Update Form
Client Full Name
*
First Name
Last Name
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
0
01
011
0111
01111
Year
Current Provider Name
*
Date of Most Recent Session
*
-
Month
-
Day
Year
Date
Are you still actively receiving services with the provider listed above?
*
Yes — I am continuing services and nothing has changed
Yes — but I have some updates (complete the sections below)
No — I have stopped seeing this provider
No — I have paused services temporarily
If anything has changed please indicate below:
Contact information changed
No
Yes — with new contact information
If Yes, please provide new contact information
Insurance status changed
No
Yes — describe below
If Yes, please describe insurance changes
Financial situation changed significantly
No
Yes — describe briefly
If Yes, please describe financial changes
Provider changed
No
Yes — with new provider information
If Yes, please provide new provider details
Any concerns about your provider or your care
No
Yes — please describe your concerns below
Yes — I prefer to contact the foundation directly at info@paperflowerfoundation.org
If Yes, please describe your concerns
Is there anything else you would like us to know?
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: