Client Application

QUEST THERAPEUTIC SERVICES, INC. - Client Registration

Date:

Patient's Name:

Sex:

Male

Female

Date of Birth:

Parent/Guardian Names:

Relation:

Parent

Grandparent

Guardian

Other

Address:

Email Address:

County:

Home Phone:

Cell Phone:

Employer Name, Address, Work Phone Number:

Emergency Contact:

Telephone:

The following information is used in summary for data collection purposes ONLY, and will remain confidential

Approximate Household Gross Income:

INSURANCE INFORMATION

Primary Insurance Company Name:

Telephone:

Case Manager/Contact:

Policy/Group Number:

ID Number:

Secondary Insurance Company Name:

Telephone :

Case Manager/Contact:

Policy/Group Number:

ID Number:

HIPPOTHERAPY HOURS OF OPERATION

There may be a waiting list, but please select the times your child is available, and our office will contact you.

Please select your availability on Mondays, Tuesdays, and Thursdays:

Please select your availability on Saturdays:

Special programming may be available at other times.

MEDICAL INFORMATION

Diagnosis:

Date of Onset:

Physician’s Name:

Physician's Practice Name:

Telephone:

Fax:

Address:

Is child receiving therapy elsewhere?:

Yes

If yes, where:

	3:00 pm	3:45 pm	4:30 pm	5:15 pm	6:00 pm
Monday
Tuesday
Thursday

Quest Therapeutic Services

Client Application

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