Client Registration

Marital Status
Legal Name?
Refered By (choose 1):
What Brings You To STREST?
Current Financial Issues? *
Have You Ever Been Diagnosed With a Mental Health Disorder? *
Do You Have a Substance Abuse Issue?: *
Have You Ever Received Treatment For Substance Abuse?: *
Do You Have A Support System?

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 *
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