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Client Information
Health Insurance Information
Insurance Information Disclosure
Client Availability
Client Information Form
Client Information
Hello, and welcome to ACES. Let’s make sure you’re starting in the right place.
Welcome Note
Welcome Note
I am new to ACES.
Welcome Note
I am returning to ACES after some time away.
Welcome Note
I am currently receiving services with ACES, but am switching to different insurances.
Welcome Note
TRICARE client: I am only seeking outcome measures.
Who will be completing and signing this form?
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.
Who will be completing and signing this form?
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
Female
Male
Other
If other, please specify:
Client Cell Number
Client Email Address
Client Address Line 1
Client Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Primary Caregiver Information
First Name
Middle Name
Last Name
Relationship To Client
Biological/Adopted Parent
Foster Parent
Sibling
Grandparent
Extended Relative
Friend/Neighbor
Nanny
Social Worker
Professional Caregiver
Other Relationship
Cell Phone
Email Address
Is there a second caregiver you would like to list?
Is there a second caregiver you would like to list?
Yes
Is there a second caregiver you would like to list?
No
First Name
Middle Name
Last Name
Relationship to Client
Biological/Adopted Parent
Foster Parent
Sibling
Grandparent
Extended Relative
Friend/Neighbor
Nanny
Social Worker
Professional Caregiver
Other Relationship
Cell Phone
Email Address
Communications Sign Off
Communication Sign Off?
Using Insurance?
Yes
No
Submitted On