Registration Form Step 1 of 5 - Client Information 20% CLIENT INFORMATIONClient Name* First Middle Last Gender* Male Female Date of Birth* MM slash DD slash YYYY Marital Status:* Single Married Other OtherAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone*Mobile Carrier:*Other Phone #s:*Is it OK to leave messages?* Yes No *Your appointment reminder may be sent by text or email. Email* ***Your monthly statements will be sent to this emailSocial Security No.*Are you employed?* Yes No What is your Occupation?Employer:Employer's Phone NumberAre you a student?* Full Time Part Time No How did you choose us?* Physician Insurance Internet Family or Friend Other How did you choose us? INSURANCE and POLICY HOLDER/SUBSCRIBER INFORMATIONRelationship to Client:* Self Spouse Parent/Guardian Other Relationship to client:Subscriber Name* First Last Gender* Male Female Date of Birth* MM slash DD slash YYYY Email* Social Security No.*Subscriber Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone*Other PhoneIs it OK to leave messages? Yes No Type of Insurance* Primary Insurance EAP Benefits Policy/Subscriber ID*Insurance Co.*Group*Occupation*Employer*Employer PhoneCongruent Counseling Services does not submit claims to secondary insurances. OTHER PARENT/GUARDIAN INFORMATIONPlease send the bill to this person (email requested)Relationship to Client:* Spouse Parent/Guardian Other Relationship to client:Gender* Male Female Name* First Last Date of Birth* MM slash DD slash YYYY Social Security No.*Email* Address, if different Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone*Other PhoneIs it OK to leave messages?* Yes No IN CASE OF EMERGENCYName of local friend or relative* First Last *Not at the same addressRelationship*Mobile Phone*Other PhoneIs it OK to leave messages?* Yes No For Medicaid ONLYDisclaimer* I agree to receive communications by text/SMS about my inquiry. Terms & Conditions: By clicking the box you agree to subscribe to Congruent Counseling Services (CCS) text/SMS services and to receive text messages from CCS. CCS will send text/SMS messages to communicate with you on the status of sessions or information requested to provide a better overall experience. For HELP, please contact us at +1 410 740 8066, or email frontdesk@ccs-ic.com. To opt-out of receiving messages, reply with “STOP” at any time. Message frequency may vary. Standard message and data rates may apply. You may review our Privacy Policy to learn more about how your data is used. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties. Δ