Client Registration
Provided by: Wellness Grove
Client Legal Name
*
First Name
Middle Name
Last Name
Client Preferred Name
Client Date of Birth
*
-
Month
-
Day
Year
Last 4 of SS# for Client
*
Your Email Address
*
Confirmation Email
example@example.com
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Client Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Social Security Number
*
Copy of Driver's License (Front Only) (Required)
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If you experience difficulty uploading a copy of your Driver's License, please contact Wellness Grove for guidance and support on communicating a copy. If the client is a minor, the driver's license can be that of the parent or guardian.
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Email Address
How did you hear about us?
*
Search Engine
YouTube
Facebook
Twitter
Instagram
Other social media
Email
Radio
TV
Newspaper
Word of mouth
Other
Were you referred to Wellness Grove by anyone working at Wellness Grove?
Yes
No
Name of Wellness Grove Staff Member
Full Name of the staff member who referred you
Address
*
Address 1
Address 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mobile Phone
*
Please enter a valid phone number.
Mobile Messages
*
Please Select
No messages
Voice messages OK
Text messages OK
Voice & Text messages OK
Home Phone
Please enter a valid phone number.
Home Messages
Please Select
No messages
Voice messages OK
Work Phone
Please enter a valid phone number.
Work Messages
Please Select
No messages
Voice messages OK
Other Phone
Please enter a valid phone number.
Other Messages
Please Select
No messages
Voice messages OK
Birth Sex
*
Male
Female
Gender Identity
*
Male
Female
Transgender Male/Trans Man/FTM
Transgender Female/Trans Woman/MTF
Genderqueer, neither exclusively male nor female
Choose not to disclose
Additional gender category or other, please specify
Sexual Orientation
*
Lesbian or gay
Heterosexual
Bisexual
Unknown
Choose not to disclose
Something else, please describe
Race
*
Language(s) (first selected will be primary)
*
Marital Status
*
Single
Married
Other
Employment
Employed
Full-Time Student
Part-Time Student
Unemployed / Other
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Is there any provider/professional that is important for your clinician to contact or collaborate with for your care?
*
Yes
No
Please note that for each provider/professional you added, Wellness Grove will send via email a request for a release of information to be filled out by you.
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We require at least one emergency contact and if the client is a minor, at least one guardian contact. For each contact that is provided, a release of information will be requested via email (with the exception of guardian contacts for minors).
*
Will you be the party responsible for payment of services?
*
Yes
No
Responsible Party Contact Name
Party responsible must be listed above as a Client Contact
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Will your counseling sessions be self pay or covered by insurance?
*
Self Pay
Covered by Insurance
Primary Insurance Information
Copy of Primary Insurance Card (REQUIRED)
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If you experience difficulty uploading a copy of your primary Insurance Card, please contact Wellness Grove for guidance and support on communicating a copy.
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Primary Insurance Carrier Name
*
Primary Policy ID #
*
Primary Policy Group #
*
Primary Insurance Policy Holider Employer (if applicable)
As indicated on primary insurance card
Client Relationship to Primary Insured (if applicable)
Relationship to Primary Insurance Policy Holder
*
Please Select
Self
Spouse
Child
Life Partner
Other Relationship
Do you have secondary insurance?
*
Yes
No
Primary Insurance Policy Holder Information
Primary Insurance Policy Holder Name
*
First Name
Middle Name
Last Name
Primary Insurance Policy Holder Birth Sex
*
Male
Female
Primary Insurance Policy Holder Date of Birth
*
-
Month
-
Day
Year
Primary Insurance Policy Holder Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Insurance Policy Holder Phone Number
Please enter a valid phone number.
Secondary Insurance Information
Copy of Secondary Insurance Card (Front & Back) (REQUIRED)
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If you experience difficulty uploading a copy of your secondary Insurance Card, please contact Wellness Grove for guidance and support on communicating a copy.
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Secondary Insurance Carrier Name
*
Secondary Policy ID #
*
Secondary Policy Group #
*
Secondary Insurance Policy Holder Employer (if applicable)
As indicated on primary insurance card
Client Relationship to Primary Insured (if applicable)
Relationship to Secondary Insurance Policy Holder
*
Please Select
Self
Spouse
Child
Life Partner
Other Relationship
Secondary Insurance Policy Holder Information
Secondary Insurance Policy Holder Name
*
First Name
Middle Name
Last Name
Secondary Insurance Policy Holder Birth Sex
*
Male
Female
Secondary Insurance Policy Holder Date of Birth
*
-
Month
-
Day
Year
Secondary Insurance Policy Holder Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Secondary Insurance Policy Holder Phone Number
Please enter a valid phone number.
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Acknowledge & Sign
By signing this form electronically and clicking on "Sign & Submit", you are certifying that the information given on this form is true and correct to the best of your knowledge. Please note that an e-signature is the electronic equivalent of a hand-written (pen-and-paper) signature.
*
Input Your Legal Name
*
Date
*
-
Month
-
Day
Year
Sign & Submit
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