Rinehart & Associates
Participant Registration Form
(Print and Fax to Rinehart & Associates)

Name:_________________________Date of Birth:______________

Address:_______________________Phone:____________________

State:______ Zip:________________e-mail:____________________

Referred By: Website or _________________________________

Relative or Friend:_________________________________________

With Whom Do You Live: __________________________________

List Family Members:

______________________________________ Age ______________

______________________________________ Age ______________

______________________________________ Age ______________

Previous or Present Psychological/Psychiatric Treatment:

________________________________________________________

________________________________________________________

Health Problems:__________________________________________

Physician's Name:________________Phone (Area Code)__________

Current Medications Being Taken:_____________________________

Any Alcoholism or Other Chronic Problems - Family or Yourself:

________________________________________________________

History of:
Alcoholism Substance Abuse
Eating Disorders Physical, Mental or Sexual Abuse

Other Chronic Problems: ____________________________________

Current Problem or Goal for Breakthrough Experience: (use back if
necessary):

________________________________________________________

Signature of Person Responsible for Payment of Account:

____________________________Date: _______________________
(Signature implies consent with policies of provider)