Winslow Guidance Associates, INC

Holbrook, AZ | Flagstaff, AZ | Apache Junction, AZ | Phoenix, AZ

This form is our Client Fact Sheet, which is required for all new clients. Please complete the form below to acknowledge your consent to treatment and program agreements.

Form 1 / 2

Client Information


Please select a title.
First Name is required.
Last Name is required.
Please provide a valid email address.
Please provide a valid cell phone number.
Please provide a valid home/message phone number.
Please provide a valid work phone number.
Please select your State.

Client Background

Please select your Sex Offender status.
Please select your Gender.
Please select your Marital Status.
Please select your Employment Status.
Please select your Ethnicity.
Please select your Race.

Treatment Services / Health Insurance Policy Information

Select a WGA location where you will receive our services:

Please select your enrolled location.

Treatment Services (Select All Services You Are Applying For):


Please select your Health Insurance Company.

Please select your Relationship to Policy Holder.

Health Care Provider Information:


*If YES, please provide a copy to the Front Desk

Emergency Contact

Emergency Contact Name is required.
Emergency Contact Phone Number is required and must be valid.
Relationship to Client is required.
Emergency Contact Work Phone Number is required and must be valid.

Client Signature is required and must be at least 3 characters.

The above information is true and best to my knowledge. I authorize my health insurance benefits to be paid directly to WGA. I understand that I am financially responsible for any outstanding balance.