Client Registration
In order for you or a loved one to become a client we first need a completed Registration and Intake Packet. If you are completing this form on behalf of a child please only input YOUR information in the responsible party section. Once we received this form we will send you our Intake Packet via Docusign. Once we receive it back, we will then send you an email confirming your health insurance benefits and offer you a session date and time. If you would like to request a particular therapist, please write their name in the section for the Preferred Therapist. If you do not have a preference, we would be happy to choose one for you based on what you write in the section for your primary reason for coming to counseling. As always, contact us with any questions, concerns, or requests for help to complete the documents.  Please call:  345-926-0882
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Email *
Client Title
Client First Name *
Client Middle Name
Client Last Name *
Client Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian
If you are completing this for a minor please provide us with your name
Cell Phone *
Please enter in 555-555-5555 format
Services you're seeking *
Required
Preferred Therapist
If you have a preference on the therapist that we assign, please indicate their name below.  If you do not have a preference, we would be happy to choose one for you based on what you write in the section for your primary reason for coming to counselling.
Have you received services with Infinite Mindcare in the past?   *
Yes or No, if so, please let us know the name of your therapist and if you'd like to see that therapist again.
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