Client Registration Form

Last Name *

First Name *

Middle Name

Birth Date *

Sex

Male

Female

Social Security Number

Employer *

Occupation *

Street Address *

City *

State *

Zip Code *

Occupation *

Employer *

Employer Phone Number

What Brings You To STREST?

Stress

Loss

Trauma

Other

Have you ever been seen by anyone for this issue?: *

If Yes, Then Whom?:

Current Medications:

Current Medical Issues:

Current Financial Issues? *

No

Yes

Have You Ever Been Diagnosed With a Mental Health Disorder? *

No

Yes

If Yes, What Was The Diagnosis and Year?:

Do You Have a Substance Abuse Issue?: *

No

Yes

If Yes To Substance Abuse, Then Elaborate:

Have You Ever Received Treatment For Substance Abuse?: *

No

Yes

If Yes To Treatment, Where & When?

Person Responsible For Payment:

Payor Birthdate

Adress If Different Than Above:

Payor Home Phone

Client Service Fees:

I, the undersigned, certify I am financially responsible for all fees associated with the services rendered through STREST. I understand STREST does not participate in any health insurance or HMO plans. I understand STREST will not submit insurance forms on my behalf and any submission of forms to my insurance provider is solely my responsibility. I understand it is my responsibility to pay the full session fee on the same date services are rendered.

Client Confidentiality:

The information contained in this electronic correspondence is confidential and intended only for the use of STREST. Any dissemination or distribution of this confidential information is strictly prohibited.

I agree That The Above Information Is True To The Best Of My Knowledge *

No

Yes

Initials *

Date *

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