WELCOME!

You are in the right place, and we are here to help with your wellness needs.

New Client Registration

First Name *

Last Name *

Phone *

Email *

Date of birth *

Gender *

Male

Female

Upload a picture of you Photo ID

Photo ID Upload

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Whom are you seeking treatment for? *

Self
Child
Parent
Family/Friend
Other
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Your name (if not client)

Your Phone # (if different from client)

Address *

City *

Postal code *

What's the Best Way to Contact You? *

Phone
Email
Text Message
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Using Insurance? *

Yes

Maybe

Who is primary on insurance?

Self

Spouse

Parent

Insurance Company

Member ID

Upload a picture of the front and back of your insurance card.

Insurance Card Pictures Upload

Would you like to receive information about treatment sent to your email? *

Yes

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages can be insecure and can pose a risk to the security and confidentiality of my protected health information and I consent to Connected Path Recovery therapists and/or office staff communicating with me via email or text message

Where did you hear about us? *

Friend/Relative

Doctor

Detox/Inpatient Facility

Employer

Social Media

Google Search

We understand that this is a big decision and step. We are here to help. We look forward to meeting you soon!

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