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

I, the undersigned certify that I am financially responsible for all charges, whether or not they are covered by insurance, associated with the services received at STREST. I understand it is my responsibility to pay the full client fee on the same date that services are rendered. In the event that payment is not received in full within thirty (30) days, a service charge may be added. I also understand that STREST will not submit insurance forms on my behalf and any submission of them to my insurance provider is solely my responsibility.

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

No

Yes

Initials *

Date *

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