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Empower Patient Registration Form

Patient
Information

PCP
Information

Parent/Guardian 1
Information

Parent/Guardian 2
Information

Primary Insurance
Information

Secondary Insurance
Information

Emergency
Contact

Services

1
2
3
4
5
6
7
8

Patient Information

Last Name

First Name

MI

Sex Male Female

Date of Birth

Street Address

City / State / Zip

Parents are Married Single Divorced

School

Address

Name of Referring Physician

Office phone#

Fax #

Next

PCP Information

Primary Care Provider (PCP) Name

PCP Clinic Name

PCP Office Phone Number

PCP Fax Number

Parent/Guardian 1 Information

Relationship to Client Father Mother Other

Last Name

First Name

MI

Sex Male Female

Date of Birth

Street Address

City / State / Zip

Cell ph

Email ID

SS#

Parent/Guardian 2 Information

Relationship to Client Father Mother Other

Last Name

First Name

MI

Sex Male Female

Date of Birth

Street Address

City / State / Zip

Cell ph

Email ID

SS#

Primary Insurance Information

Financially Responsible Party Parent 1 Parent 2

Insurance Company Name

Primary Insured Parent 1 Parent 2

Policy ID #

Policy Group #

Insurance provider service phone #

Upload insurance id card (Front & Back)

Secondary Insurance Information

Insurance Company Name

Primary Insured Parent 1 Parent 2

Policy ID #

Policy Group #

Insurance provider service phone #

Upload insurance id card (Front & Back)

Emergency Contact

Contact Name

Home ph

Work ph

Relationship to Client

Comments

Authorized to release medical or client information to this contact? Yes No

Responsible party signature

Date

Emergency Contact

Interested in the following services

ABA Therapy

Occupational Therapy

Speech Therapy

Counseling

Life coaching

Signature

Date