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Child Registration Form - Responsive Centers For Psychology

Child Registration Form - Responsive Centers For Psychology 2025

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The document is a Client Registration Form for children at Responsive Centers for Psychology and Learning. It includes sections for client and parental information, financial policies, consent for treatment, confidentiality agreements, and biographical details about the child. The form outlines the clinic's policies regarding appointments, payment responsibilities, and the handling of sensitive information in therapy sessions.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the CLIENT INFORMATION section. Enter the child's last name, first name, middle initial, birth date, age, and sex. This information is crucial for identifying your child.
Next, complete the address fields including street address, city, state, and zip code. Ensure that contact numbers are accurate for effective communication.
In the MOTHER’S and FATHER’S INFORMATION sections, provide similar details for both parents including names, birth dates, social security numbers, and contact information.
Review the DIVORCE POLICY section carefully and acknowledge your understanding by signing where indicated.
Fill out the FINANCIAL POLICY section to clarify payment responsibilities. Choose between private pay or insurance options as applicable.
Complete any additional sections such as BIOGRAPHICAL INFORMATION and PRESENTING PROBLEMS to give a comprehensive overview of your child's needs.

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