Register for Services

Registration is simple.  If you are a prospective client begin your registration over the phone (parent or guardian may register a minor).  See our LOCATIONS page for hours of operation, phone and fax numbers.  Or, you may download a registration packet from the link below.  Or, call and request a registration packet to be mailed to your home address.

Submit registrations completed remotely to the desired clinic location via email scan, USPS mail or fax.  After the registration is processed, you will be given an appointment for a clinical intake.

Bring with you or send copies of the following items:

  • All current Insurance Cards – primary and secondary
  • Photo ID
  • Patient Social Security Card
  • Primary Medical Doctor’s name, address and phone number

If Patient is a minor, you will also need to bring in or send copies of:

  • Proof of custody ( Custody order)
  • Proof of address
  • Immunization record
  • Birth certificate

If you currently have no insurance, please bring in or send copies of the following for income verification:

  • 3 most current pay stubs  OR
  • Prior year tax return

Choose the packet that applies to your situation:

Print and fill out either the Adult or Child Information Packet, whichever applies to your situation. If you cannot print out the Information Packet, you can fill it out when you arrive for registration. But it is a great time saver if you can do it in advance.

Download/print Adult Information Packet

Download/print Child Information Packet

Notes:

Children are not required to attend the registration meeting.

Acceptance and schedule for intake is dependent on qualifying for services, and if required, obtaining authorizations for services.

Failure to provide all necessary documents can result in no scheduled clinical visits.

Please be advised that there is a Wait List for ALL private insurance. In order to be added to the list, the registration process must be completed.


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The danger in posting out of excitement is that a mistake is made. The good news in correcting the mistake is that we can once again profusely thank an organization for its kindness. THANK YOU BRENT CARROLL AND THE CENTREVILLE LIONS CLUB FOR YOUR GIFT OF CLEAR VISION TO CHARLES WILSON. ... See MoreSee Less

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