CarePlus client self-registration
All transactions are secure and encrypted Enter the client's information below
Enter the client's information below
Personal Information
Client First Name
*
First Name is required
Client Middle Name
Client Last Name
*
Last Name is required
Date of Birth
*
Invalid date
Gender
*
- Please select -
Female
Male
Transgender - presents as Female
Transgender - presents as Male
Gender is required
Referral Reason
*
- Please select -
Case Management
Groups - Mental Health
Other
Substance Abuse
Therapy/Counseling
Referral Reason is required
Insurance card
🏠 Home Address
Street address
*
Street address is required
City
*
City is required
State
*
- Please select -
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Unknown
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
State is required
Zip Code
*
-
Zip Code is not valid
Contact Information
📧 Email
*
Email is required
Email is not valid
📱 Mobile phone
*
Mobile phone is not valid
Best time to call
*
- Please select -
9-12p M-F
12-3p M-F
3p-5p M-F
Best Time To Call is required
Continue
Email Verificaton
We sent a verificaton code to your Email.
Enter the 6-digit code
Get new code
Code is required
Invalid code
Continue
Phone Verificaton
We sent a verificaton code to your mobile.
Enter the 6-digit code
Get new code
SMS code is required
Invalid SMS code
Continue
Register
Error
Success