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Seasons

Demographic Form

Thank you for completing the Seasons Center Demographic Form. Someone from Seasons will contact you within 48 business hours to gather any missing information, send additional paperwork and to schedule an appointment. If you have any questions, please contact us at 1-800-242-5101.

No clients will be denied access to services due to the inability to pay. We offer a discounted/sliding fee schedule available to those who qualify.

Personal Information

Client Name (Required)

Client Address (Required)

City, State, Zip (Required)

Phone Number (Required)

Date of Birth (Required)

Household Income (Required)

Employment Status (Required)

Living Arrangement (Required)

Marital Status (Required)

Last Grade Completed (Required)

Spoken Language (Required)

If Other, Please Enter Language Spoken (Required)

What can we help you with & what services are you interested in?

Insurance

Do You Have Insurance? Yes No

Insurance Carrier

Policy Number

Phone Number on Back of Card

Guardian

Do you have a guardian? If so, who?

Guardian Phone Number

Emergency Contact

Relationship to Client

Address

City, State, Zip

Phone Number

Primary Medical Doctor

Address

City, State, Zip

Phone Number

Pharmacy

Address

City, State, Zip

Phone Number

Our Locations

Mission

Guiding individuals and families towards a meaningful and fulfilling life.

Vision

Best in the Midwest in Behavioral Health

Values

Innovation, Impact, Influence

Seasons

Demographic Form