Client Registration Form

Download the PDF version with the above link or use the form below to submit online

Online Form Submission

Are you a returning client?(required) Yes

If yes, what was your last name when you were last seen here?

Client's Legal Name (First, Middle, Last)(required)

Client's Preferred Name

Full Street Address(required)

Home/Primary Phone(required)

Work Phone

Cell Phone

Email Address(required)

Best Number For Appointment Reminders(required)

Call or Text?(required) Call

Text

Others that may be contacted for schuling:

Name

Phone

Marital Status(required)

Gender(required)

Birthdate(required)

Age(required)

Social Security(required)

Referred By

Primary Care Physician(required)

Past Therapy/Treatment/Evaluation (Name, approximate dates)(required)

Employer(required)

Occupation(required)

Employer's Full Address(required)

Spouse's Name

Spouse's Date of Birth

Spouse's Employer

Spouse's Employer Full Address

Spouse's Home Phone

Spouse's Work Phone

Spouse's Cell Phone

Additional Information When a Client is Minor (Only provide information NOT given above)

Mother’s Infomation

Mother

Mother's Date of Birth

Step-Father (if any)

Full Address

Phone

Employer

Occupation

Employer City/State

Work Phone

Father’s Infomation

Father

Father's Date of Birth

Step-Mother (if any)

Full Address

Phone

Employer

Occupation

Employer City/State

Work Phone

Legal Guardian(s) (if other than parents)

Child's School

Grade

School Contact Person

Title

Other People Living in Home (Name, Age, Relationship)

Primary Insurance

Carrier

Policy Holder

Policy Holder's DOB

Relationship to Client

Policy #

Group #

Policy Holder's SS#

Secondary Insurance

Carrier

Policy Holder

Policy Holder's DOB

Relationship to Client

Policy #

Group #

Policy Holder's SS#

PAYMENT DUE AT TIME OF SERVICE: Payment for your portion of charges is due at the time of service unless other arrangements with the provider have been made. Appointments must be canceled at least 24 hours in advance or you may be billed for missed or late canceled appointments.

Check here to acknowledge you've been made aware of this policy(required)

Who is responsible for payment of this account?(required)

If our biller would need to contact you, what is the best number to reach?(required)

Is it OK to leave messages?(required) Yes

If you have any questions about psychotherapy or our office policies, please ask before checking the box below. Checking the agreement box below indicates that you have read our office policies and that you seek and agree to enter mental health services under those conditions. You understand that no promises have been made regarding results of any treatment or procedure provided by the provider. Further, it indicates your understanding the Psychological Associates of the Black Hills may terminate servicesif there is a lack of compliance with these policies or if the provider believes you are not benefiting from treatment.

Consents

Consent for Evaluation and Treatment: Consent is given for evaluation and treatment to the provider and Psychological Associates of the Black Hills. I understand that at times cases are staffed anonymously between the professional staff; I consent to this procedure. It is agreed that either the provider or I may discontinue evaluation, consultation, and/or treatment at any time and that the client is free to accept or reject the services offered or provided.
Assignment of Insurance Benefits/Payment Agreements: Psychological Associates of the Black Hills or the providers’ billers will file all insurance claims unless otherwise directed. If the client or responsible party is entitled to insurance benefits of any type arising from any policy which insures the client or other liable person, those benefits are hereby assigned to the provider for credit toward balances on the client account. The client and/or responsible party shall be financially responsible for any charges not paid by insurance. If payment is not made directly to the provider by insurance, payment, in full, is due from the client and/or responsible party. The undersigned agrees to pay the provider the assessed charges, in full, at time of service unless other arrangements have been authorized. Please note, there will be a $45.00 feeon all NSF checks. Psychological Associates of the Black Hills reserves the right to charge1.5%interest and/or late fees on statements for accounts 60 days past due and not paid in a timely manner. It is the clients’ and/or responsible parties’ responsibility to set up a payment plan if they cannot pay their statement in full. If client’s account is past due, records release may be postponed until payment is madeon account. Note to Separated/Divorced Parents: Psychological Associates of the Black Hills will NOT bill the other parent unless that parent coordinateswith us. It is your responsibility to seek any reimbursement from the other parent. If your child is a client, you are requested to inform the other parent that your child is receiving services at Psychological Associates of the Black Hills.
Release of Information for Medical Insurance Coverage to Insurance, Managed Care, or EAP: To process and determine benefits payable, I hereby authorize my provider to release any necessary part of the client’s record, as specified by the Notice of Privacy Practices, toany insurance carrier or entitlement program, which may be obligated to pay all or part of treatment charges. A photocopy of this authorization shall be considered as effective and valid as the original. This authorization shall remain in effect and validuntil this office receives a written revocation signed by the client or other authorized person. I certify that the information I have furnished is true and correct. Psychological Associates of the Black Hills bills through a variety of companies. Check with office personnel for provider-specific contact numbers. Personal checks, that identify you, will be presented for deposit at your provider’s financial institution.
Consent for the use of Email and Texts: Psychological Associates of the Black Hills cannot guarantee but will use reasonable means to maintain security and confidentiality of email and text communications. By checking the box below the client and/or responsible party is acknowledging and consenting to receive non-encrypted email and text communications.
Notice of Privacy Practices: I acknowledge that I have received the Notice of Privacy Practices from Psychological Associates of the Black Hills.

I have read this document in full, I am the client or responsible party, and I agree to its terms and conditions(required)