Client Registration Form

Full name:
Date of birth:
Gender: FemaleMaleNon-binary
Race:
Ethnicity:
Marital Status: singlemarried
Religion:
Occupation:

Client Contact Information

Phone:
Address:
Email:

Emergency Contact Information

Full name:
Phone:
Relationship:

Primary Care Physician

Name:
Address:
Phone:

 

Referral (How did you hear about us?):

 

 

Client Signature (12 or older)


The above information is true and correct, I consent to the storing of my information in cloud -based electronic health record system utilized by Roamers Therapy LLC.

Date:

You can draw your signature on the gray area below.



 

 

Next step: Informed Consent form →