Pre-Registration Form

Welcome to FSGC!

We know how tough it is to live with mental health challenges or to watch your child struggle to make friends or to behave at school and home. All of us at Family Service & Guidance Center want the best for you and your family. Whether you live with anxiety, depression, ADHD, trauma, substance use or another challenge, FSGC is here to assess what’s going on and provide the appropriate treatment.

The fastest, easiest way to get started is to pre-register. Once you complete the form and click “Submit,” an FSGC staff member will call to set your first appointment.

Fill in the spaces below and click “Submit” when finished to send your form to us. FSGC Admissions will contact you to set up your appointment. (NOTE: An asterisk * indicates required information.)

A tall dark-haired woman in a blue jean jacket warmly embraces a happy young boy who is wearing a blue T-Shirt and sneakers on a park path.

Get Started

Pre-Registration Form

"*" indicates required fields

Child's First Name*

Child's Last Name*

Parent/Guardian First Name*

Parent/Guardian Last Name*

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*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian Email*

Child's Date of Birth

School*

Current grade*

Children's Doctor*

Insurance Information

Do you have insurance?

Yes

Insurance Policy

Insurance Company

Insurance ID#

Insurance Group #

Insured Name

Insured Date of Birth

Insured Employer

Insured Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Comments

This field is for validation purposes and should be left unchanged.