Heritage Counseling Associates 

555 Dayton St., Ste C 

Edmonds, WA 98020 

Office: 425-774-4673 

Fax: 425-774-0690 

                                                                         Client Registration Form 

CLIENT 

Last name, First Name, Initial _________________________________________________________________

Birthdate ________ / _______ / _______Age ______Social Security # _________________________________  

I:I Male 

I:I Female 

​Address _________________________________________________________ Home Phone ___________________________________  

City, State ________________________________________ Zip ____________ Cell Phone ______________________________  

Employer ________________________________________________________ Occupation______________________________  

Information for Spouse, or Parent/Guardian (if client is minor) 

(if client is under 18) Grade___ School _________________________________________________________________  

Name:

Last name, First Name, Initial_____________________________________________________________________

     Male 

     Female 

Birthdate ______ / _______ / ______ Age _____________________ Social Security # _______________________________________  

Address _________________________________________________________ Home Phone____________________________________________  

City, State _______________________________________ Zip ____________________ Cell Phone ______________________________________  

Employer _______________________________________________________________ Occupation _____________________________________  

Spouse' Name  _______________________________________________________ Birthdate ______________________________  

How were you referred to this office? _______________________________________________________________________  

Your Primary Care Physician: _________________________________________________ Phone ____________________________  

Emergency Contact? ________________________________________________________ Phone ____________________________  

PERSON RESPONSIBLE FOR BILL, IF NOT CLIENT  

Name _________________________________________________________ Relationship to client _______________________________  

Address ________________________________________________ Birth Date / / SS# __________________________  

City, State _______________________________________ Zip ____________________ Home Phone ____________________________________  

Employer ____________________________________________________________ Work Phone _____________________________________  

INSURANCE INFORMATION 

Client's Relationship to Subscriber 

Insurance Co. _______________________________________________________________________________ Self Spouse Dependent 

Subscriber ______________________________________________________________________ Birthdate / /  

Subscriber's ID # _________________________________________________________ Group # ________________________________________  

Is insurance authorization needed? _________ Have you obtained? What is the amount of your co-payment? _______________  

ASSIGNMENT AND RELEASE: I hereby authorize my insurance benefits to be paid directly to the provider of service. I am financially responsible for any balance due. I also authorize the doctor/provider or insurance company to release any information required for this claim. 

Please  -  Sign Client or Guarantor's Signature,_________________________________________  Date.______

Important -  Payment is expected at the time of service. All balances due are payable within 30 days. Accounts with balances over 60 days will be 

charged a finance charge of $10.00 per month. Missed appointments and cancellations without 24 hours advanced notice will be charged. 

Initial__________