Client Enrollment Form
Please complete this confidential enrollment form.
Education-Prevention-Wellness
Williams and Associates, Inc
3737 North Kingshighway Blvd. Ste. 206
St. Louis MO 63115
(314) 385-1935
First Name
Your answer
What name would you prefer to be called?
Your answer
Last Name
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Are you ok receiving mail at this address?
Cell Phone
Your answer
Is it ok to leave a message?
Emergency Contact Person (ECP) and Relationship
Your answer
ECP Telephone
Your answer
Is it ok to discuss with ECP?
Date of Birth
Your answer
Age
Your answer
Gender
Race
Highest Education
Are you currently attending school?
if yes, please list where
Your answer
Are you currently working?
If yes, please list where
Your answer
How did you hear about the agency or program?
Who were you referred by?
If by an agency, please list telephone and agency number.
Your answer
Presenting Problem (s): Check all that apply
Programs or services you want to participate in: (check all that apply)
Comments
Feel free to write any comments in the box below.
Your answer
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
Your answer
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