Client Registration Form  (Revised 04/30/15 LB)                               

Cost Center Location:                         Client ID:
 
 Last Name:      First Name:           MI:            Suffix:

SSN:              Birthday:        Gender:

Alias:
Last Name:                     First Name:

 Birth Last Name:      Birth FName:      Mother's First Name: 

Driver's License/State ID #:            State Issued: 

* PFN:     (Required by SACPA)         * CDC:    (* Required by SACPA Parole)

* Other Identifiers: 

Address Type:      Home             Homeless         If client is homeless and MediCal eligible, please see DADS billing manual.

Street Address:        Apt. #: 

City:        State:      Zip Code: 

Preferred Contact Type:   Home        Bus. Phone       Cell Phone          Email           Fax        Pager           Alternate

Phone/Fax/Pager #:              Email / Alternate: 

If born in the U.S., what is your State of Birth?  (If not, input country of birth)  

If born in California, what is your County of Birth?  (If not, input N/A)    

Language preferred for Treatment:          

Veteran:    Yes            No           Declined to State

Ethnicity:

 DA - Not Hispanic      Mexican/Mex. American       DA - Cuban        DA - Puerto Rican       DA - Other Hispanic/Latino

Race:

  White   Chinese   Laotian
  Black / African - American   Filipino   Samoan
  American Indian   Guamanian   Vietnamese
  Alaskan Native   Hawaiian   Other Asian
  Asian Indian   Japanese   Other Race
  Cambodian   Korean   Multi Racial

 

Input required on all fields except *                                    ** Enter as appropriate                           

Confidential Client Information: California Welfare and Institutions Code Section 5328 - 42 CFR and Title 42, Code of Federal Regulations, Part 2