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Center Associates - SBYS Registration Form (2023-2024)
Child's Full Name:
*
Date of Birth
*
+
Child's Social Security Number
Biological Sex
*
Male
Female
Ethnicity (Click all that apply)
*
White
Hispanic/Latino
Black or African American
Asian
American Indian and Alaskan Native
Hawaiian/Pacific Islander
Other
Other
Gender Identity (Optional)
Male
Female
Non-Binary
Other:
Other:
Preferred name; if different than birth name (Optional)
Preferred Pronouns (Optional)
School Attending:
*
Current Grade:
*
Primary Reason for initiating school based therapy:
*
Parent/Guardian Information
Parent #1 Information
Parent/Guardian #1 Full Name:
*
Parent/Guardian #1 relationship to child:
*
Mother
Father
Legal Guardian
Other
Other
Address of Parent #1
*
Is this the child's primary living address?
*
Yes
No
Other
Other
Parent #1 Speaks what language(s)?
*
English
Spanish
Other
Other
Parent #1 Phone Number
*
Is this the child's primary contact number?
*
Yes
No
Other
Other
Parent #2 Information
Parent/Guardian #2 Full Name:
*
Parent/Guardian #2 relationship to child:
*
Mother
Father
Legal Guardian
2nd Parent does not have legal custody (must provide documentation)
Other (May need to provide documentiation)
Other (May need to provide documentiation)
Address of Parent #2
Is this the child's primary living address?
Yes
No
Other
Other
Parent #2 Phone Number
*
Is this the child's primary contact number?
Yes
No
Other
Other
Parent #2 Speaks what language(s)?
*
English
Spanish
Other
Other
Does this child have other siblings? (Check all that apply)
Yes - Living in the same home
Yes - Living in a different home
No
Other:
Other:
Total number of siblings:
Child's Medical Information
Name of Child's Primary Care Doctor
Primary Care Doctor's Facility Name
*
Child's Current Medication and Dosage:
Child's allergies:
List any previous mental health or substance abuse agencies/providers
Payment/Insurance Information
Does this child have insurance coverage?
*
Yes
No
Waiting on insurance coverage
Other
Other
Policy Holder Name on Insurance Card:
*
Insurance ID Number:
*
Name of Health Insurance Company
*
Reason for waiting on insurance coverage or not having insurance coverage
*
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Center Associates
3809 South Center St.
Marshalltown, IA 50158