Call 913-696-1400 Today!



Minor Registration Form




PATIENT INFORMATION
First Name (Required):

Marital Status (Required):


Middle Name (Required):

Birth Date (Required):

Last Name (Required):

Gender:


Social Security Number (Required):

Cell Phone:

Email Address (Required):

Other Phone:

Address Information (Required):



Referred By:

Emergency Contact Name of local friend or relative (not living at same address) (Required):

Relationship to the Patient (Required):

Work Phone Number:

Cell Phone Number (Required):

Occupation:

Persons with whom you live, their ages and their relationship to you:

Education Level (Required):

BIOLOGICAL MOTHER’S INFORMATION (IF APPLICABLE)
Mother’s First Name:

Marital Status:


Mother’s Middle Name:

Mother’s Email Address:

Mother’s Last Name:

Mother’s Cell Phone:

Mother’s Address Information (only if different from above):



Mother’s Other Phone:

Mother’s Education Level:

Mother’s Occupation:

All accounts are the responsibility of the individual patient or guardian and payments are to be made at the time of the appointment. This office will assist you in filing insurance, but takes no responsibility for denial of or delay in payment. A CHARGE WILL BE MADE FOR APPOINTMENTS NOT CANCELLED WITHIN 24 HOURS. I authorize the provider to release to my insurance company(ies) and their bona fide agent(s) such information as may be required to adjudicate my claim, I authorize direct payment to medical benefits to the provider and I hereby assign and set over to such provider all of such benefits. I understand that I am financially responsible to the provider for charges not covered by this authorization.

BIOLOGICAL FATHER’S INFORMATION (IF APPLICABLE)
Father’s First Name:

Marital Status:


Father’s Middle Name:

Father’s Cell Phone:

Father’s Last Name:

Father’s Other Phone:

Father’s Address Information (only if different from above):



Father’s Email Address:

Father’s Education Level:

Father’s Occupation:

INSURANCE INFORMATION
Person Responsible for the bill:
Birth Date:
Address (if different):

Cell Phone (if different):
Is this person a patient here?
 Yes No		Occupation:
Employer:
Employer Address:

Employer Phone:
Please indicate primary insurance:
Insurance Company Address:

Subscriber’s Name:

Subscriber’s Social Security Number:

Date of Birth:

Group Number:
Policy Number:
Insurance Company Phone:
Patient’s Relationship to Subscriber:
 If other, please explain:
MEDICAL HISTORY
Primary Care Physician (Required):

Date of Last Physical (Required):

Spouse or Partner Name (Required):

Spouse or Partner Occupation (Required):

  
Medical History:

 Head Injury Learning Problems Alcoholism Substance Abuse Hepatitis Chicken Pox Rheumatic Fever Thyroid Problems Cancer Sinus Problems Food Intolerance Asthma Speech Problems Anorexia/Bulimia Tuberculosis Special Diets Hypertension Stroke Anemia Kidney Disease Hypoglycemia Heart Problems Neurological Disease Gastrointestinal Problems Sexually Transmitted Disease None

 

Do you have allergies to food or medications?

 Yes No

If so, please list:

Do you experience any of the following?

 Abdominal Pain Changes in Appetite Dizziness Bed Wetting Headaches Fatigue Frequent Urination Fainting Spells Chest Pain Menstrual Problems Breathing Problems Nausea Colds Nosebleeds Constipation Sore Throat Coughs Toothache Sore Throat Diarrhea Vomiting Ear Infection Eye/Vision Problems Memory Problems Numbness None

List any operations or hospitalizations for medical, psychiatric, drug or alcohol problems and their dates:

Are you involved with the court system?

 Yes No		If so, what is the issue?

Do you use any of the following (Required)?

 Alcohol Tobacco Nonprescription Drugs Prescription Drugs None
Please explain use, frequency/dosage, and if prescribed include the reason:

Note any adverse reactions to the medication listed above:

Please list any supplement or homeopathic medication you are taking:

What has brought you to this office? (Check all that apply)

 Depression Moodiness Illness Anxiety Relationship Issues Family Problems Traumatic Experience Children Grief/Loss Sexual Problems Anger Other		If other, please explain:

Are you currently having suicidal ideation (Required)?

 Yes No		 
Have you had previous counseling (Required)?

 Yes No
If yes, please state where and the counselor’s name:

Have you had contact with a Psychiatrist for medication or evaluation (Required)?

 Yes No
If yes, please state where and the Psychiatrist’s name:

Click Here to Download the Patient Agreement and minor consent form Check here if you accept the terms of the Patient Agreement. By checking this box I acknowledge my digital signature to the above information.
 

All accounts are the responsibility of the individual patient or guardian and payments are to be made at the time of the appointment. This office will assist you in filing insurance, but takes no responsibility for denial of or delay in payment. A CHARGE WILL BE MADE FOR APPOINTMENTS NOT CANCELLED WITHIN 24 HOURS. I authorize the provider to release to my insurance company(ies) and their bona fide agent(s) such information as may be required to adjudicate my claim, I authorize direct payment to medical benefits to the provider and I hereby assign and set over to such provider all of such benefits. I understand that I am financially responsible to the provider for charges not covered by this authorization.


Popular Posts Widget

Spouse Selection
4 Comments
Featured Image
Revealing Truth
4 Comments
Featured Image
True or False
4 Comments

Twitter Widget

Coaching

  • Monty W. Miller, BA Psych, MSW Monty holds a license in the State of Kansas as a Licensed Specialist Clinical Social Worker with over twenty-eight years of experience working with families and couples.

Counseling

  • Leawood Counseling Center Leawood Counseling Center is a group of individual private practitioners who have come together to offer services to assist in facilitating change in individual’s lives.
  • Monty W. Miller, BA Psych, MSW Monty holds a license in the State of Kansas as a Licensed Specialist Clinical Social Worker with over twenty-eight years of experience working with families and couples.
  • Shelley L. Bartel, LSCSW Specializing in relationship difficulties, addiction issues and interpersonal dysregulation, Shelley empowers a mindfulness of change through powerful exploration and reframing of hardship and difficulty.

Health


Copyright Bryan E. Vignery, Inc. 2005 -2012. All Rights Reserved.
%d bloggers like this: