Client Registration - New Perspectives for Life

First Name *

Last Name *

Date of birth *

Month *

Day *

Year *

Current Age

Phone *

Email Address *

Gender *MaleFemalePrefer not to say / Other

School

Place of Employment

Street address *

Apartment, suite, etc

City *

State *

ZIP / Postal Code *

Reason for Visit *

Spouse / PartnerPlease enter information about the client's spouse / partner.

Name

Phone

Email Address

ParentsPlease enter information about the client's parents.

Name

Phone

Email Address

SiblingsPlease enter information about the client's siblings.

Name

Phone

Email Address

Lives withPlease enter information about people the client lives with. If they are listed above, please just enter their name — you do not need to re-enter their phone number and email.

Name

Phone

Email Address

Emergency contactsPlease enter information about emergency contacts for the client.

Name *

Phone *

Email Address *

Primary care doctor's first name.

Primary care doctor's last name.

PhonePrimary care office phone number.

Street AddressPrimary care office street address.

Apartment, suite, etcPrimary care office apartment or suite.

CityPrimary care office city.

State/ProvincePrimary care office state.

ZIP / Postal CodePrimary care office zip.

Previous diagnoses

MedicationCurrent & previous medications.

Other informationOther significant medical conditions and information.

Hospital/Facility Inpatient Dates & Location

Outpatient Programs Dates & Location

First Name *Client first name.

Last Name *Client last name.

I authorize New Perspectives for Life, LLC to release information relevant to services provided to the following people/organizations (If you do not wish to authorize consent to release to anyone, please scroll down and click next.):

SchoolPlease enter information about the client's current school, if any.

Name

Phone

Email Address

ChurchPlease enter information about the client's current church, if any.

Name

Phone

Email Address

PhysicianPlease enter information about the client's current physician, if any.

Name

Representative

Phone

Email Address

AttorneyPlease enter information about the client's current attorney, if any.

Name

Representative

Phone

Email Address

OtherPlease enter information about any other organizations the client belongs to that may need to receive information.

Organization name

Representative

Phone

Email Address

Signature

Statement of Confidentiality

New Perspectives for Life, LLC upholds strict confidentiality in regard to each client and family. Information shared by the client/family is utilized for treatment purposes only.

New Perspectives for Life, LLC may only go outside of client confidentiality in the following situations:

Information is needed by others in the community (i.e. school, physician) AND the client/guardian has signed a consent to release of information for the specific community entity.
Suicidal ideation in which the client expresses intention and/or plan to harm oneself.
Homicidal ideation in which the client expresses intention and/or plan to harm another person.
Abuse in which the client is receiving or has received abuse by another person which has not previously been reported.
Abuse in which the client is abusing or has abused another person which has not previously been reported.

Signature of Client / Guardian *

All payments, whether for a single session or a session package, must be made in full at time of service. All payments are non-refundable. Pre-paid packages expire in the same allotment of months (3-session pkg/3 months, 6-session pkg/6 months and 10-session pkg/10 months) from date of purchase.

Signature of Client / Guardian *

Referred by

Name of place, or person, of referral