Registration Form CLIENT INFORMATIONName Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Marital Status If not, what is your legal name? (Former name): Birth DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeSex Address Street Address City State / Province / Region ZIP / Postal Code Home/Cell Phone #Occupation Employer Name Employer Phone #Best place to leave a message Referred by: Insurance Plan Hospital Family Friend Close to home/work Online (Please specify) Other (Please name) Referred by, please specify Referred by, please name INSURANCE INFORMATIONPerson responsible for bill Birth DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address if different Street Address City State / Province / Region ZIP / Postal Code Home/Cell Phone if differentOccupation Employer Employer Phone NoEmployer Address Street Address City State / Province / Region ZIP / Postal Code Please indicate primary insurance Policy No. Group No. Co-payment/ co-insurance In case of emergency, notify The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Bradley S. Sears, M.A., LCPC. I understand that I am financially responsible for any balance. I also authorize my therapist or insurance company to release any information to process my claims.SignatureDate MM slash DD slash YYYY