Center Associates - SBYS Registration Form (2022-2023)

Patient Full Name: *

Date of Birth * +

Biological Sex: *

Male

Female

Race: *

Gender Identity (Optional):

Male	Female
Non-Binary	Other: Other:

School Attending: *

Current Grade: *

Primary reason for initiating school based therapy: *

Parent/Guardian 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

Other Other

Parent #1 Phone Number: *

Is this the child's primary contact number: *

Yes

Other Other

Parent/Guardian #2 full name:

Parent/Guardian #2 relationship to child

Mother

Father

Legal Guardian

Other Other

Address of Parent #2

Is this the child's primary living address?

Yes

Other Other

Parent #2 Phone Number:

Is this the child's primary contact number:

Yes

Other Other

Does this child have other siblings in the home?

Yes	No
Other Other

How many siblings:

Child's Medical Information

Child's Primary Care Doctor:

Child's Current Medications/ Dosage:

Child's Medication Allergies:

List any previous mental health or sustance abuse agencies/providers:

Payment/Insurance Information

Insurance Coverage:

Yes

Policy Holder Name on Card:

Insurance ID Number:

If yes, Name of Insurance:

Center Associates

3809 South Center St.

Marshalltown, IA 50158