Client Enrollment Form
Please complete this confidential enrollment form.
Williams and Associates, Inc
3737 North Kingshighway Blvd. Ste. 206
St. Louis MO 63115
What name would you prefer to be called?
Are you ok receiving mail at this address?
Is it ok to leave a message?
Emergency Contact Person (ECP) and Relationship
Is it ok to discuss with ECP?
Date of Birth
More than one race
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Are you currently attending school?
if yes, please list where
Are you currently working?
If yes, please list where
How did you hear about the agency or program?
Through a relative or friend
Referred by an agency
At a program or activity
Who were you referred by?
If by an agency, please list telephone and agency number.
Presenting Problem (s): Check all that apply
Programs or services you want to participate in: (check all that apply)
Many Men Many Voices
Feel free to write any comments in the box below.
I am affirm and attest that the information on this application is true and factual. My signature on this form is voluntary. I consent and understand that my signature on this form grants approval for the agency staff to contact me in the manner that I have stated. I understand that participation is voluntary and that I agree to follow all agency/program rules, protocols, and guidelines related to my participation. I understand that the agency will take the strictest measures to protect the confidentiality of my personal information.
Signature of Client and Date
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