CROSSINGS CLIENT INFORMATION FORM First Name Last Name Address City State Zip Home Phone Cell Phone Email Address Date of Birth Occupation Emergency Contact Emergency Contact Phone Would you like to receive the Crossings Newsletter? YesNo How would you like to receive Appointment Reminders? TextEmail Is there any discretion necessary when contacting you about your appointment time at home or work? If yes, please specify. Cancellation Policy: If you need to change or cancel your appointment , please do so 24 hours in advance to avoid being charged a cancellation fee.