Child (5-13) Counseling Registration Form
Requestor's Information
Child's Information
Parents' / Legal Guardian's Information
Please provide the details about BOTH parents or ALL legal guardians
Custody Disclosure
Appointment Scheduling
Insurance Information
ID / Insurance Cards
In accordance with the government requirements to prevent medical insurance fraud, we require all of our clients to provide us with a copy of a state or federally issued personal identification document bearing a photo of the individual seeking services, such as driver’s license, state ID card or passport. We do not accept birth certificates or Social Security Numbers as proof of identify. Please note we are unable to schedule your first appointment without having received your ID card(s).
If you experience an issue uploading images of your ID cards, you may alternatively email us the photos of your cards to forms@vitacounseling.com.
YOUR REQUEST HAS BEEN SUBMITTED SUCCESSFULLY! WE WILL BE IN TOUCH SHORTLY TO SCHEDULE YOUR FIRST APPOINTMENT.
THERE WAS AN ISSUE WITH YOUR FORM SUBMISSION. PLEASE TRY AGAIN OR CALL US AT 855.826.8482. APOLOGIES FOR THE INCONVENIENCE THIS MAY HAVE CAUSED YOU
VITA Counseling Partners Online Client Registration
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