Teen (14-17) Counseling Registration Form
Parents' / Legal Guardian's Information
Please provide the details for BOTH parent or ALL legal guardians.
ID / Insurance Cards
In accordance with government requirements to prevent medical insurance fraud, we require all of our clients to provide us with a copy of state or federally issued personal identification document bearing a photo of an individual seeking services, such as driver’s license, state ID card or passport. We do not accept birth certificates or Social Security Numbers as the proof of identify.
If you experience an issue uploading images of your ID cards, you may alternatively email us the photos of your cards to firstname.lastname@example.org.