Registration Forms
PRIMARY FORMS
- You will need Acrobat to open & print a PDF - FREE download here
ADULT INFORMATION - PDF (Print & Write-In) or Online Registration
- Your contact information and basic demographics.
- You will need Acrobat to open & print a PDF - FREE download here
CHILD INFORMATION (Age 15 and Younger)
- PDF (Print & Write-In) or Online Registration
- Child / Adolescent contact information and basic demographics.
- ADOLESCENT HISTORY (Age 16 - 18) - PDF (Print & Write-In) or Online Registration
- ADOLESCENT comprehensive background history.
SUPPLEMENTAL FORMS
- HIPAA CONSENT - PDF (Print & Write-In) or Online Registration
- Policies regarding Protected Health Information (PHI).
- RELEASE OF INFORMATION - PDF (Print Your Copy) / Online Review
- Your consent to disclose/share your CHILD'S medical records to a third party, if applicable.
Questions? Call 239-599-5656