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New Client Registration Forms
New Client Registration Forms
Welcome to The Rock Counseling Group. To assist us in gathering important information prior to your initial appointment we please ask that you complete the following forms prior to the first session in our office.
New Client Registration Form
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  • 1
    Please provide full legal name
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  • 3
    Please provide preferred name, if different from legal name, If no preferred name please enter "none"
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    Please enter in MM/DD/YYYY Format
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  • 5
    Please enter the age of client in years
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  • 6
    If you have an apartment number or unit number please put in "address line 2"
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    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
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    • Belize
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    • Burkina Faso
    • Burundi
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    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
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    • Djibouti
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    • Guyana
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    • Malawi
    • Malaysia
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    • Marshall Islands
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    • Mexico
    • Micronesia
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    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
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    • Netherlands Antilles
    • New Caledonia
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    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
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    • Tuvalu
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    • Vatican City
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    • Vietnam
    • British Virgin Islands
    • Isle of Man
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    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
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    • Other
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  • 7
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  • 8
    If you have an apartment number or unit number please put in "address line 2"
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    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
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    • Connecticut
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    • Florida
    • Georgia
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    • 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
    • Puerto Rico
    • Rhode Island
    • South Carolina
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    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virgin Islands
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 9
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  • 11
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  • 12
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  • 13
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  • 14
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  • 15
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  • 16
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  • 17
    Please choose gender assigned at birth
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  • 19
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  • 20
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  • 24
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  • 25
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  • 26
    Chose the option that best applies to the client
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  • 27
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  • 28
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  • 29
    • Pre-K
    • 1st Grade
    • 2nd Grade
    • 3rd Grade
    • 4th Grade
    • 5th Grade
    • 6th Grade
    • 7th Grade
    • 8th Grade
    • Freshman High School
    • Sophomore High School
    • Junior High School
    • Senior High School
    • Highs School Graduate
    • Freshman College
    • Sophomore College
    • Junior college
    • Senior College
    • Completed some college
    • Current Graduate Student
    • Completed Graduate school
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  • 30
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  • 31
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  • 32
    • Spouse
    • Husband
    • Wife
    • Partner
    • Mother
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    • Sibling
    • Grandparent
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    • Friend
    • Other
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  • 33
    (###) ###-####
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  • 34
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  • 35
    • Spouse
    • Husband
    • Wife
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    • Mother
    • Father
    • Stepmother
    • Stepfather
    • Guardian
    • Child
    • Sibling
    • Grandparent
    • Aunt
    • Uncle
    • Friend
    • Other
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  • 36
    (###) ###-####
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  • 37
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  • 38
    • Spouse
    • Husband
    • Wife
    • Partner
    • Mother
    • Father
    • Stepmother
    • Stepfather
    • Guardian
    • Child
    • Sibling
    • Grandparent
    • Aunt
    • Uncle
    • Friend
    • Other
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  • 39
    (###) ###-####
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  • 40
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  • 41
    Chose option that best applies to the client
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  • 42
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  • 43
    Please make sure full card is in view
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  • 44
    Please make sure full card is in view
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  • 45
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  • 46
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  • 47
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  • 48
    Please Provide your member ID number including all letters or numbers
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  • 49
    Please Provide your member ID number including all letters or numbers, please do not provide you RX or BIN #
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  • 50
    This number is typically on the back of your insurance card
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  • 51
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  • 52
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  • 53
    Please enter in MM/DD/YYYY Format
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  • 54
    If you have an apartment number or unit number please put in "address line 2"
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    • Alabama
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    • New Hampshire
    • New Jersey
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    • Ohio
    • Oklahoma
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    • Puerto Rico
    • Rhode Island
    • South Carolina
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    • Utah
    • Vermont
    • Virgin Islands
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
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    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
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    • Western Sahara
    • Yemen
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    • Zimbabwe
    • Other
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  • 63
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  • 64
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  • 65

    I *     *    by my signature on the next page, I acknowledge that I have read, understand, and agree to informed consent treatment as outlined in the "informed consent for treatment" document.

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  • 66
    Signature of client over the age of 18 or Parent/ Legal Guardian if client is under 17 years old
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  • 67
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  • 68

    I *     *    by my signature on the next page, I acknowledge that I have read, understand, and agree to the limits of confidentiality as outlined in the "limits of confidentiality and privacy practices" document.

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  • 69
    Signature of client over the age of 18 or Parent/ Legal Guardian if client is under 17 years old
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  • 70
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  • 71

    I *     *    by my signature on the next page, I acknowledge that I have read, understand, and agree to the fee disclosure and client payment responsibility agreement as outlined in the "fee disclosure and client payment responsibility agreement" document.

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  • 72
    Signature of client over the age of 18 or Parent/ Legal Guardian if client is under 17 years old
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  • 73
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  • 74

    I *     *    by my signature on the next page, I acknowledge that I have read, understand, and agree to the verification of insurance and submitting billing to your insurance provider as outlined in the "verification of insurance and submitting billing to your insurance provider" document and you agree to allow The Rock Counseling Group to release information to insurance companies as required for billing including electronic billing/ data submission if appropriate. You also agree to authorize payment directly to The Rock Counseling Group by your insurance carrier unless otherwise agreed upon with The Rock Counseling Group.  

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    Signature of client over the age of 18 or Parent/ Legal Guardian if client is under 17 years old
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  • 76
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  • 77

    I *     *    by my signature on the next page, I acknowledge that I have read, understand, and agree to terms of appointment reminders, missed appointments, cancellation, and no show fees as outlined in the "Appointment reminders, missed appointments, cancellation fees, and no-show fees" document.

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  • 78
    Signature of client over the age of 18 or Parent/ Legal Guardian if client is under 17 years old
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  • 79
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  • 80

    I *     *    by my signature on the next page, I acknowledge that I have read, understand, and agree to how behavioral health records will be handled as outlined in the "Behavioral Health Medical Records" document.

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  • 81
    Signature of client over the age of 18 or Parent/ Legal Guardian if client is under 17 years old
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  • 82
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  • 83

    I *     *    by my signature on the next page, I acknowledge that I have read, understand, and agree to the information provided regarding contacting my therapist, emergency services, and crisis intervention as outlined in the "Contacting your therapist, Emergency services, and Crisis intervention".

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  • 84
    Signature of client over the age of 18 or Parent/ Legal Guardian if client is under 17 years old
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  • 85
    Please choose the best option
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