Client Registration

Title
Marital Status
Legal Name?
Sex
Refered By (choose 1):
What Brings You To STREST?
Symptoms
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?

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 *
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