Registration Form Step 1 of 5 - Client Information 20% CLIENT INFORMATIONClient Name* First Middle Last Gender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Marital Status:*SingleMarriedOtherOtherAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone*Mobile Carrier:*Other Phone #s:*Is it OK to leave messages?*YesNo*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?*YesNoWhat is your Occupation?Employer:Employer's Phone NumberAre you a student?*Full TimePart TimeNoHow did you choose us?*PhysicianInsuranceInternetFamily or FriendOtherHow did you choose us? INSURANCE and POLICY HOLDER/SUBSCRIBER INFORMATIONRelationship to Client:*SelfSpouseParent/GuardianOtherRelationship to client:Subscriber Name* First Last Gender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Email* Social Security No.*Subscriber Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone*Other PhoneIs it OK to leave messages?YesNoType of Insurance*Primary InsuranceEAP BenefitsPolicy/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:*SpouseParent/GuardianOtherRelationship to client:Gender*MaleFemaleName* First Last Date of Birth* Date Format: MM slash DD slash YYYY Social Security No.*Email* Address, if different Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone*Other PhoneIs it OK to leave messages?*YesNo 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?*YesNo For Medicaid ONLY Δ