Pre-Registration Intake

Please provide the requested information to the best of your ability.

To complete a registration: fill out every section that applies to your situation below, upload any documents requested (ID, court order, insurance card), and submit. Someone from our team will follow up once we've reviewed what you send.

Fields marked with an asterisk (*) are required when shown. Some fields only apply to certain situations — fill in what's relevant to you and leave the rest blank.

About You

First Name *

Last Name *

Date of Birth *

Gender

Male Female Other

What is your email address? *

Cell phone no. *

Is it OK for us to text you at this number? *

Yes No

Address *

Address 2

City *

State *

Zip *

Legal / Court

Only fill this in if a court is involved in your case.

Judge

Which court issued the referral? *

Miami-Dade Broward Palm Beach Other

Is there an Injunction? *

An "Injunction" may also be called a restraining order or no-contact order.

Yes No

Who is it between?

Has a Guardian Ad Litem been appointed by the court?

Yes No

What is the Guardian's name?

Guardian's email

Guardian's phone

What is your attorney's name?

Attorney Email

Attorney Phone

Identifying ID

Identifying ID Type *

Driver's License State Issued ID Passport

ID Number

ID Issuing State

Passport Number

Marital & Relationship

Marital Status *

Married Separated Divorced Never Married

How long have you been in this relationship?

If you are separated, how long have you been apart?

Coparent

Coparent First Name

Coparent Last Name

Date of Birth

Coparent Gender

Male Female Other

Coparent email

Coparent phone

Coparent Attorney Name

Coparent Attorney Email

Coparent Attorney Phone

What is your current visitation or timesharing schedule?

How do you currently communicate with your coparent?

Information about your Children

How many children are participating in these services? *

Only fill in the children participating in these services.

Child 1

First Name

Last Name

Date of Birth

Child 2

First Name

Last Name

Date of Birth

Child 3

First Name

Last Name

Date of Birth

Child 4

First Name

Last Name

Date of Birth

Child 5

First Name

Last Name

Date of Birth

Do any of your children have special needs or concerns? Please explain.

Please list any allergies, behavior concerns, or other diagnoses

Have your children had previous treatment for those special needs or concerns? Please describe the treatment they have received.

As a parent, do you have other specific concerns for your children that we need to be aware of? Please explain.

Substance Use Testing

IMPORTANT: This form does not schedule your drug test. There are no walk-ins, it is by appointment only.

Drug tests are only available at the Ft. Lauderdale location.

Once the form is submitted, there will be more information sent to you to sign. Procedures, policies and scheduling will occur after signed documents and payment have been received.

Urine Testing

5-Panel Urine Drug Screen 10-Panel Urine Drug Screen I do not know

Hair Follicle Testing

5-Panel Hair Follicle Test 10-Panel Hair Follicle Test 12-Panel Hair Follicle Test 14-Panel Hair Follicle Test I do not know

If your hair is braided or has any attachments (Extensions, etc), these will need to be removed prior to any hair follicle test.

Nail testing coming soon. Breath Alcohol (EtOH) testing coming soon.

Other/Special Instructions

If your test is faulty, you will be required to test again within 3 hours. You will not be able to leave the facility during this time and must remain under observation. You will be allowed to drink water if it is a urine test.

Billing Information

Referral Type

Company / Employer Self Pay / Personal Childnet Other

If Other, please fill in the referral below

Company / Employer Name

Company Contact

Company Phone

Company Email

Company Address

In the event my employer does not pay for the Substance Use testing, I acknowledge that I am responsible for all costs related services and will provide payment information during the registration process.

Self-pay clients must provide payment and a valid email address for results at the time of service. Billing will only accept credit cards.

Will you be using your insurance? *

f.a.c.e.s. currently only accepts Aetna and Cigna insurance.

Yes No

Please enter the name of your insurance provider *

Please also upload a picture of the insurance card in the Documents section below.

Payment Arrangement

Describe who is paying and how (e.g. split between parents, percentages, employer-paid).

Documents

If you upload a document, please make sure to include ALL pages of the document.

Please upload a photo of your Driver's License (or equivalent form of ID). *

Please upload a photo of your Insurance Card *

Please upload your Court Order/Referral *

Please upload your Company provided Protocol and Authorization Form with billing instructions

Upload any additional documents (court orders, referrals, or other related items)

Please be sure all necessary/requested documents have been attached. Pre-Registration cannot be fully processed if required documentation is missing.

Each file must be a photo (JPG, PNG, HEIC/HEIF) or PDF up to 25MB, up to 5 files per field.

Thank you

Your pre-registration has been received. A member of our team will follow up with you soon.

Pre-Registration Intake

About You

Services

Legal / Court

Identifying ID

Marital & Relationship

Coparent

Information about your Children

Child 1

Child 2

Child 3

Child 4

Child 5

History

Substance Use Testing

Billing Information

Documents

Thank you