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

VITA Counseling Partners Online Client Registration
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