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Prodigal Kids
New Client Registration Package
NEW CLIENT ENROLLMENT
Select the service that you desire to enroll in and indicate where you would prefer to receive services.
Substance Abuse Services: (Includes Individual, Group, and Family Therapy)
Prevention Education - to prevent the onset of substance use
Intervention Services - early intervention of substance use
Intensive Outpatient Program (IOP) - substance abuse and mental health
Mental Health Services:
Individual Therapy
Group Therapy
Family Therapy
Service Delivery Location
Prodigal Kids Campus
School
Daycare/Preschool
In the Home
Is transportation needed?:
Yes
No
CLIENT FACESHEET
First Name
*
Last Name
*
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Date of birth:
*
+
Phone Number
*
Social Security Number
*
🛈
Client's School or Daycare Name
*
Race/Ethnicity
*
Place of Birth
*
Religion
*
Email Address
*
Marital status
*
Single
Married
Divorced
Widowed
Employment Status
*
Full-time
Part-time
Unemployed
Student
Gender
*
Male
Female
Financial Guarantor Information
First Name
*
Last Name
*
Date of birth:
*
+
Email Address
*
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Social Security Number
*
🛈
Employment Status
*
Full-time
Part-time
Unemployed
Student
Relationship to Client
*
Employer Name
*
Employer Phone Number
*
I understand that I am responsible for any balance not paid by the insurance.
*
Insurance information
My health insurance is in my name
Primary insured name
*
Date of birth:
*
+
Social Security Number
*
🛈
Street Address
*
Address Line 2
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
Zip Code
*
Phone Number
*
Email Address
*
Insurance coverage provided by
*
Member Identification number
*
Group number
*
Phone Number on the Insurance Card
*
Primary Care Provider
*
Primary Care Provider Street Address
*
Primary Care Provider City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
Zip Code
*
PCP Phone Number
*
Attach an image of the insurance card
Attach file
Secondary Insurance Provider
Address
Member Identification Number
Phone Number on Insurance Card
Attach an image of second insurance card
Attach file
Referral Information
Referral Source
*
Self Referral (I found Prodigal Kids on my own)
Primary Care Provider
Department of Juvenile Justice (DJJ)
Department of Corrections
Psychologist
Psychiatrist
Local Hospital
Other
Other
Referral Agency Name
Is this a DJJ case?
*
Yes
No
Probation Officer's Name
Probation Officer's Phone Number
Caseworker's Name
Caseworker's Phone Number
(c) 2017 Prodigal Kids - All Rights Reserved.