CCD Registration Form
Primary Client is a Minor (v. 202410)
ID
Location
My Therapist/Case Manager is:
*
Please Select
Claudia Alvarez, LPC Associate
Lori Cadwallader, LPC
Alondra Benitez, LCSW
Rebekah dePeo-Christner, LPC
Jacob Doering, LPC
Hannah Garcia-Mooney, LMSW
Marcos Gonzalez, LPC
Sadaf Meckfessel, LPC
Cindy Jacobson, LPC
"Jake" Jacobson LCSW
Crystal Janes, Masters Intern
Zahra Mamdani, LPC Associate
Michelle Moore, LPC
Isabel Murray, Masters Intern
“Terri” O’Banon, LMSW
Sunnie Palmer, LCSW
"Casey" Robertson, LPC Associate
Rebecca Torres-West, LPC
Tina Taylor, LPC
I don't know/None of the above
TH1
Date Of First Session
*
-
Month
-
Day
Year
Date
Information about the Youth
YOUTH LAST NAME
*
YOUTH FIRST NAME
*
YOUTH MIDDLE INITIAL
DATE OF BIRTH
*
/
Month
/
Day
Year
Date
AGE
*
SEX (Required for some 3rd Party Pay Sources)
*
Please Select
Female
Male
PREFERRED PRONOUNS
Please Select
She/ Her
He/ Him
They/ Them
Other
CURRENT OCCUPATION/STUDENT
*
EMPLOYER/SCHOOL
*
PLEASE LIST ANY CURRENT MEDICATIONS OR MEDICAL CONDITIONS
BRIEFLY DESCRIBE THE REASON YOU ARE SEEKING COUNSELING
*
INFORMATION ABOUT THE PARENT/GUARDIAN
PARENT/GUARDIAN NAME
*
(2) First Name
(2) Last Name
(2) Date of Birth
*
/
Month
/
Day
Year
(2) Date
(2) AGE
*
(2) SEX (Required for some 3rd Party Pay Sources)
*
Please Select
Female
Male
(2) PREFERRED PRONOUNS
Please Select
She/ Her
He/ Him
They/ Them
Other
(2) OCCUPATION/STUDENT
*
(2) EMPLOYER/SCHOOL
*
(2) RELATION TO CLIENT LISTED ON PAGE ONE
*
PARENT/GUARDIAN HOME ADDRESS
*
CITY
*
COUNTY
*
STATE
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
*
PHONE
*
EMAIL
*
example@example.com
IN CASE OF EMERGENCY CONTACT INFORMATION
FIRST/LAST NAME
*
RELATIONSHIP TO CLIENT
*
CONTACT PHONE
*
WHO REFERRED YOU TO US?
NAME
*
AGENCY
*
CLIENT or PARENT GUARDIAN SIGNATURE
*
DATE
*
/
Month
/
Day
Year
Date
Are there additional clients or parent/guardian to add?
Yes
ADDITIONAL COUNSELING PARTICIPANTS OR AUTHORIZING ADULTS
CLIENT #3 NAME
*
(3) First Name
(3) Last Name
(3) Date of Birth
*
/
Month
/
Day
Year
(3) Date
(3) AGE
*
(3) SEX (Required for some 3rd Party Pay Sources)
*
Please Select
Female
Male
(3) PREFERRED PRONOUNS
Please Select
She/ Her
He/ Him
They/ Them
Other
(3) OCCUPATION/ STUDENT
*
(3) EMPLOYER/ SCHOOL
*
(3) RELATION TO CLIENT LISTED ON PAGE ONE
*
Add Client #4?
Yes
CLIENT #4 NAME
*
(4) First Name
(4) Last Name
(4) Date of Birth
*
/
Month
/
Day
Year
Date
(4) AGE
*
(4) SEX (Required for some 3rd Party Pay Sources)
*
Please Select
Female
Male
(4) PREFERRED PRONOUNS
Please Select
She/ Her
He/ Him
They/ Them
Other
(4) OCCUPATION/ STUDENT
*
(4) EMPLOYER/ SCHOOL
*
(4) RELATION TO CLIENT LISTED ON PAGE ONE
*
Add Client #5?
Yes
CLIENT #5 NAME
*
(5) First Name
(5) Last Name
(5) Date of Birth
*
/
Month
/
Day
Year
Date
(5) AGE
*
(5) SEX (Required for some 3rd Party Pay Sources)
*
Please Select
Female
Male
(5) PREFERRED PRONOUNS
Please Select
She/ Her
He/ Him
They/ Them
Other
(5) OCCUPATION/ STUDENT
*
(5) EMPLOYER/ SCHOOL
*
(5) RELATION TO CLIENT LISTED ON PAGE ONE
*
Add Client #6?
Yes
CLIENT #6 NAME
*
(6) First Name
(6) Last Name
(6) Date of Birth
*
/
Month
/
Day
Year
Date
(6) AGE
*
(6) SEX (Required for some 3rd Party Pay Sources)
*
Please Select
Female
Male
(6) PREFERRED PRONOUNS
Please Select
She/ Her
He/ Him
They/ Them
Other
(6) OCCUPATION/ STUDENT
*
(6) EMPLOYER/ SCHOOL
*
(6) RELATION TO CLIENT LISTED ON PAGE ONE
*
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