Client Information
  First Name:  * Last Name:  *  
  Date of Birth:  * Gender:  *  
  Address: City:  
  State: Zip Code :  
  Phone No:  
* ELECTRONIC SIGNATURE    By entering my email address or home address in this box, I am signing this Practice Orientation Agreement and Coordination of Care. I hereby certify that I am either the client as entered above or a parent/legal guardian for the client. I agree to the terms and conditions set forth in this agreement. My signature below indicates that I consent to receive services at Wentworth & Associates, that I understand I may discuss any questions I have regarding services, and that I maintain the option to terminate my consent at any time. I have been re-oriented to the practice and understand my rights and responsibilities as a client.
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Save and Exit" button to save recent updates and exit the form.
  3. Click the "Save and Print" button to save recent updates and print the form.
  4. Click the "Cancel" button to exit without saving recent updates on this form.