Registration Form

There are 4 forms required for the child/family application process: Registration Form, Symptoms Checklist, Child's Biography, and Parents' Biography.

PLEASE READ THESE INSTRUCTIONS (IPHONE/DROID NOT RECOMMENDED!):

• You must provide your e-mail address (5th line down on the form) in order to save your responses and then retrieve your saved responses at a later time. If you do not provide an e-mail address, you must submit each form in its entirety in one session. Without an e-mail address on record, you will not be able to save your responses!
  
  
• Periodically as you are filling out each form, click on the "Save Form" button at the bottom of the page and then continue with the form where you left off. Your responses up to that point will be saved.
  
  
• If you need to stop and take a break, click on the "Save Form" button at the bottom of the page, just as you had been doing periodically. You may close your browser.
  
  
• When you return from your break, enter JUST your e-mail address (5th line down), and then click on the "Retrieve Form" button at the bottom of the page. Your saved responses up to that point will be retrieved.
  
  
• When each form is complete, click on the "Submit Forms" button on the bottom of the page. Your completed form will be submitted and all saved responses will be erased. Do not submit the form until you are done. You will not be able to continue updating a submitted form.
  
  

Completed By:			Child's Name:
Street Address:
City:			State:
Zip Code:
E-MAIL ADDRESS:			Child's Date of Birth:		(mm/dd/yyyy)
Date:		(mm/dd/yyyy)	Child's Social Security Number:		(nnn-nn-nnnn)
Home Phone:		(nnn-nnn-nnnn)	FAX:		(nnn-nn-nnnn)
Mobile Phone:
Mother's Information:
Mother's Name:			Employer:
Occupation:			Business Phone:
Father's Information:
Father's Name:			Employer:
Occupation:			Business Phone:
Others living at home. Please include Gender, Age, School, and Grade, as applicable.
Other Caregivers. Please include daycare, family members, etc.
Reason for seeking treatment.
Child's History:
Is the Child Adopted?   Yes     No
History of abuse, neglect, trauma, or significant separations.
Previous treatment and diagnosis (dates, length of treatment, results).
School Information:
School:			Grade:
Teacher:			Counselor:
Teacher's Phone:			Counselor's Phone:
Comments.
Family Information:
Parents' marriages, separations, divorces.
Who wants Help?
Mother's main concerns?
Father's main concerns?
Five adjectives describing mother.
Five adjectives describing father.
Five adjectives describing marriage.
Five adjectives describing child.
Physician & Referral Information:
Family Physician:			Physician's Phone:
Referred By:			Phone:
Credit Card (VISA/MC) Information:
Name on Credit Card:			VISA     MasterCard
Credit Card Number:			Expiration Date:
			CV   (3 digits on back of card):
Street Address (must match your credit card statement):
City:			State:
Zip Code:
Phone:			E-mail: