Child (5-13) Counseling Registration Form

Requestor's Information

First Name

M.I.

Last Name

Contact Email Address

Phone Number

In case we need to reach you, how would you like us to contact you?

When is the best time to reach you?

Child's Information

First Name

M.I.

Last Name

Client's Mailing Address

City

State

Zip Code

Client's Gender

Client's DOB

Client's SSN

Do you wish to provide Emergency Contact?

Emergency Contact Name

Phone Number

Relationship to Client

Parents' / Legal Guardian's Information

Please provide the details about BOTH parents or ALL legal guardians

Relationship to Child

Parent's / Legal Guardian's Full Name

Parent's / Legal Guardian's DOB

Parent's / Legal Guardian's Email

Parent's / Legal Guardian's Phone Number

Parent's / Legal Guardian's Mailing Address

City

State

Zip Code

Custody Disclosure

Is there a Custody Order present?

Attach Custody Order

Name of Individual holding Sole Custody

Appointment Scheduling

Reasons for seeking counseling (provide a brief description)

Appointment Preferences

Appointment Language Preference

Appointment Type Preference

Appointment Reminder Preference

Mobile Phone Number

Home Phone Number

Insurance Information

Will you be utilizing your medical insurance to pay for services?

Insurance Company Name (as it appears on the card)

Subscriber's Name

Subscriber's DOB

Subscriber's SSN

Client Relationship to Subscriber

Subscriber's Employer

Mental Health Phone # (on back of ID Card)

Insurance Card ID#

Insurance Card Group Number

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).

Would you like to upload your ID cards at this time?

Driver's License / State ID (FRONT)

Driver's License / State ID (BACK)

Insurance Card #1 (FRONT)

Insurance Card #1 (BACK)

Insurance Card #2 (FRONT)

Insurance Card #2 (BACK)

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

Label: Your Field Value

Palmerton Office

Easton Office

Child (5-13) Counseling Registration Form

Requestor's Information

Child's Information

Parents' / Legal Guardian's Information

Custody Disclosure

Appointment Scheduling

Insurance Information

ID / Insurance Cards

OUR MISSION:

OUR VISION:

USEFUL LINKS:

Registration Forms

Telehealth

Online Pay

Contact Us

OUR LOCATIONS:

Easton Office

3735 Easton-Nazareth Hwy, Suite 102

Easton, PA 18045

OUR LOCATIONS:

Palmerton Office

3295 Forest Inn Rd, Suite 3

Palmerton, PA 18071