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 →



       
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