*Complete Registration Package

Registration Paperwork

Demographic and Insurance Information

Date * +

Social Security Number 🛈

GenPsych Location (please select) *

Patient First Name *

Middle Initial

Last Name *

Street Address *

Apt, Complex #

City *

State *

Zip Code *

Mobile Number *

Alternate Number

Email Address *

Date of birth: * +

Age *

Gender *

Male

Female

Marital status *

Single

Married

Divorced

Widowed

Attach image of drivers license

Will patient require administration of any medication during program hours? *

Yes

No

Unsure

If yes, please list medication, dosage and frequency of administration: *

If patient is a minor, please list the following Parential Information

Parent Name:

Relationship:

Type of Custody:

Parent Name:

Relationship:

Type of Custody:

Is someone other than the above Legally Responsible for patient? *

If Yes, Legal Guardian name(s): *

* If applicable, please submit any custodial orders to the administrative staff