Tru-Rob Counseling and Consulting LLC
Therapy/QBHS Registration Form
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Visit Requested:
In-Person
Virtual
No Preference
Under Age 18
Client Information:
Name:
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Format: (000) 000-0000.
Email:
example@example.com
Parent Information:
Name:
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If different from minor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Insurance Information:
InsuranceCarrier:
MemberID:
Group Number:
Self
SubscriberName:
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
EAP:
AuthorizationCode:
#of sessions
Reason for Referral:
Submit
Should be Empty: