LCCS Pre-Registration Form

LCCS Pre-Registration Form
Location*

MinnesotaMichigan
Is this a Referral?*

Yes (Agency or organization)No, (new Client, spouse or parent of new client)
Name of person giving referral

First NameLast Name
Email of person giving referral
example@example.com
Phone number of person giving referral
Please enter a valid phone number.
Client Type*

AdultMinorCouple
Programs*

Therapy - AdultTherapy - MinorTherapy - Couples (Relationship)Adult Rehabilitative Mental Health Services (ARMHS)Case ManagementOther
Client Name*

First NameLast Name
Client Birth Date *

MonthDayYear
Date
Preferred Name
Client Phone Number
Please enter a valid phone number.
Client Email
example@example.com
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Information
Parent Name*

First NameLast Name
Parent Phone Number
Please enter a valid phone number.
Parent Email
example@example.com
Parent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client #2
Client #2 Name*

First NameLast Name
Client #2 Phone Number
Please enter a valid phone number.
Client #2 Email
example@example.com
Client #2 Birth Date*

MonthDayYear
Date
Client #2 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Provider
Preferred Provider - 1st Choice
Preferred Provider - 2nd Choice
Appointment Information
Best Day of Week for Appointment
Best Times for Appointments
ARMHS
Client goal areas:

MedicalEmploymentFinancialDentalEducationSocial SkillsChemical UseHousingIndependent living SkillsOther
Primary Insurance
Insurance Type*

InsuranceSelf PayThird Party
Full Name*

First NameLast Name
Primary Insurance
Policy #
Group #
Member/Subscriber #
File Upload (Click to take picture. Upload picture of all insurance cards front and back)

Cancelof
Notes
Should be Empty:

LCCS Pre-Registration Form

Parent Information

Client #2

Preferred Provider

Appointment Information

ARMHS

Primary Insurance