Client Registration Form

Welcome and thank you for choosing Psychological Associates of the Black Hills!

Date:
Are you a returning client? YesNo
If returning client, what was your last name when you were last seen here?
Client's Legal Name (First, Middle, Last)
Preferred Name
Street Address
City State Zip
Phone: Cell Home Work
email address
Best Number for Appointment Reminders: CallText
Others that may be contacted for scheduling: Name: Phone:
Marital Status: SingleMarriedDivorcedSeparatedWidowedLong-Term Partner
Gender: Birthdate: Age: SS#:
Past Therapy/Treatment/Evaluation (Name, approximate dates)

Employer: Occupation:
Employer Address:
Spouse's Name: Spouse's Birthdate:
Spouse's Employer: Employer City/State:
Spouse's Phone Cell Home Work

Step 2