Pre-registration Form

Pre-Registration Form

Welcome!

We understand what it’s like to watch your child struggle at home, at school and in the community. Just like you, our dedicated professionals want the best for them. Whether your child lives with anxiety, depression, ADHD or another mental health issue, Family Service & Guidance Center is here to assess what’s going on and provide the appropriate treatment.

Pre-registration is the quickest, easiest way to get started. Once you complete and submit the pre-registration form, an FSGC staff member will be in touch soon by phone to arrange your first appointment.

Complete the information below. Be sure to click "Submit" to send your form to us. FSGC Admissions will contact you to set up your appointment. (NOTE: An asterisk * indicates required information.)

Child's name

Parent/Guardian name

Parent/Guardian relationship

Best phone number to call

Best time to call between 7:30 a.m. and 5 p.m.

Who referred you for services?

What are your concerns for this child?

Address, City, State and Zip

Parent/Guardian Email

Child's Date of Birth

Child's Gender

School

Current Grade

Child's Doctor

Insurance Information

Do you have insurance?

Yes

Add your primary insurance company policy information below.

Insurance Company

Insurance ID#

Insurance Group#

Insured Name

Insured Date of Birth

Insured Employer

Insured Full Address (Address, City, State and Zip)

Add your second insurance company policy information below.

Insurance Company

Insurance ID#

Insurance Group#

Insured Name

Insured Date of Birth

Insured Employer

Insured Full Address (Address, City, State and Zip)

Add your third insurance company policy information below.

Insurance Company

Insurance ID#

Insurance Group#

Insured Name

Insured Date of Birth

Insured Employer

Insured Full Address (Address, City, State and Zip)

Pre-Registration Form

Insurance Information

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