NEW CLIENT REGISTRATION | Bluedoorpsych

Client Form

Client Registration

Client 1 - First name

Last name

Date of Birth

Address

City/State

Zip Code

Gender

Male

Female

Non-binary

Other

Phone

Email

May we leave a message at this number?

Yes

No

Emergency Contact Name

Relationship to client

Phone

Current Medications

Client 2 - First Name

Last name

Date of Birth

Address (if different from above)

City/State

Zip Code

Gender

Male

Female

Non-binary

Other

Email

Phone

May we leave a message at this number?

Yes

No

Emergency Contact Name

Relationship to client

Phone

Current Medications

If referred by someone, who?

May we thank them for referring you?

Yes

No

Describe your primary concern

Mental Health/Medical Professionals

Click here to download Release of Information Form

Financially responsible party

Click here to download Treatment Consent & Financial Information

Click here to download Credit Card Authorization Form

Upload File

Billing Address (if different from above)

Treatment Consent & Financial Policies

Upload File

Credit Card Authorization

Upload File

I acknowledge that I understand this is a nonsecure form and I consent to submit my information via this format. *If you do not consent, please contact us via phone to coordinate

Your Signature

Select a date

Client Form

Client Registration

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