Online Registration Form

We’re happy that you’ve chosen CHOICES, Inc. as your new behavioral health provider. To help you prepare for your intake appointment, we’ve put together this online registration questionnaire to help us gather information about you. Please, have your health insurance information nearby. 

CHOICES, Inc. has a policy of complying with the Health Insurance Portability and Account- ability Act of 1996 (HIPAA). Our objective is always to be 100% compliant. The information you provide us with is confidential.

We ask that you review the following documents prior to completing our registration forms:

If do not wish to apply for services using our online questionnaire, please print and complete our paper Registration Form

If you have any records that you think will help us take better care of you, please bring them to your appointment. We look forward to meeting you!

Sincerely,
CHOICES, Inc.

  • Basics
  • Insurance Informaiton
  • Your Medical and Psychological History.
  • Submit

Identification

Your name (First, Middle, Last)

Your date of birth:

What is your home address?

Home Address

City, State, ZIP

What is your mailing address (If different from home address)?

Mailing Address

City, State, ZIP

Phone number:

Is it ok to leave a message on this phone number?

Your email address:

Is it ok to email you?

Have you ever been a client of CHOICES, Inc?

Who referred you to CHOICES, Inc.? How did you hear about us?

To meet requirements for our funding sources, we ask every applicant the following questions. Please, select all that may apply to you.

What is your race/ethnicity? (Select all that applies)

Your gender identity:

Sexual Orientation:

Are you a US Veteran?

Are you homeless?

Primary Insurance

Please be aware that most insurance companies require you to authorize CHOICES, Inc. to provide them with a clinical diagnosis. Sometimes, insurance requests additional clinical information such as treatment plans, or summaries. This information will become a part of the insurance company files. It is important to remember that you always have the right to pay for counseling services yourself if you do not wish to share such information with your insurance company. We will ask you to read and sign Insurance Authorization when you come in for your first appointment.

Do you have health insurance coverage?

Your insurance:

Policy number/Client ID

Group Number

Reasons for seeking help:

What concerns have led you to seek help?

When did this begin to be a problem for you?

Where is this impacting you the most?

What do you hope to gain from becoming a client of CHOICES, Inc.?

Past treatment history:

Have you ever been diagnosed with a psychiatric, sub stance abuse, learning, emotional, or behavioral disorder??

Have you previously taken medication to treat psychological problems?

Have you ever been hospitalized or received inpatient treatment for psychological issue?

Symptom Checklist

Please indicate which of the following areas are currently problems for you. Check all that apply:

Tips for receiving the best care possible:

1. Review, print, and complete all Registration Forms. Bring them with you to your first appointment. 2. Arrive promptly for your visit. 3. Bring your insurance ID card. 4. List of current medications including doses and frequency. 5. Read our Notice of Privacy Practices

Submit your application for services

Please, type your First and Last name