Client Information Form

Client Information
Health Insurance Information
Insurance Information Disclosure
Client Availability

Client Information

Hello, and welcome to ACES. Let’s make sure you’re starting in the right place.

Welcome Note

I am new to ACES.
I am returning to ACES after some time away.
I am currently receiving services with ACES, but am switching to different insurances.
TRICARE client: I am only seeking outcome measures.

Who will be completing and signing this form?

I am the parent, legal guardian, and/or authorized representative of a person receiving services who is under eighteen (18) years of age, or a conserved adult.
I am the person who will be receiving services and am over eighteen (18) years of age and not under conservatorship.

Client Information

Client First Name

Client Middle Name

Client Last Name

Client Birth Date

Client Sex

If other, please specify:

Client Cell Number

Client Email Address

Client Address Line 1

Client Address Line 2

City

State

Zip Code

Primary Caregiver Information

First Name

Middle Name

Last Name

Relationship To Client

Cell Phone

Email Address

Is there a second caregiver you would like to list?

YesNo

First Name

Middle Name

Last Name

Relationship to Client

Cell Phone

Email Address

Communications Sign Off

Communication Sign Off?

Using Insurance?

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