Getting Started at Lifeway Counseling Centers-test

Welcome to Lifeway Counseling Centers. Please complete
the ‘Getting Started’ information form below and our Intake Coordinator will call you, and have the
opportunity to learn a little more about your counseling needs and preferences prior to scheduling.

Thank you for trusting LifeWay with your care!
Please fill out the selected form below.

It is LifeWay’s policy, and a clinical best practice,
that clients who need medication also need to be engaged in therapy for successful outcomes. Our
psychiatrists and nurse practitioners treat clients who are in therapy with a LifeWay counselor.
Specific conditions such as ADD/ADHD and certain referrals from community therapists can be treated
at LifeWay without a LifeWay therapist.

Child and adolescent treatment at LW, and a clinical
best practice, will always require the participation of one or more primary caregivers. Our goal is
to empower parents and children to enjoy a healthy connection so that both will thrive.

Who will be participating
in the counseling?*

First Name*

Last Name*

Date Of Birth*

Gender*

Address/street*

City*

State/Province*

Zip*

Home Phone

Mobile Number is Mandatory

Mobile Phone*

Work Phone

Email is Mandatory

Email Address*

Was
child recommended for psychological testing?

Name of The Person
Recommending

Specific type of
Psychological testing if known

Parent or Guardian
information

First Name*

Last Name*

Date Of Birth *

Gender *

Address/street*

City*

State*

Zip Code*

Home Phone*

Mobile Number is Mandatory

Mobile Phone*

Work Phone*

Email is Mandatory

Email Address*

What are your hopes and goals in counseling?

Tell me how your life is going to be different once your hopes and goals in
counseling are achieved?

Please write down any doubts or fears related to counseling that you are
experiencing?

Faith
Association

Would Integrating Your Spirituality be Beneficial to you

Emergency Contact Information

Name

Phone

Relation

Do You Plan On Using
Insurance?*

If you choose insurance as ‘Yes’, Please upload
both front and back part of insurance card in button provided below

Insurance Company*

Member ID*

Group #

Please Upload Insurance Front Image

Upload Insurance Front Image

Please Upload Insurance Back Image

Upload Insurance Back Image

Responsible party for payment:

Name

Phone#

Address/street

Organisation Name

If Family/Marriage/couples, counseling second adult
person information

First Name

Last Name

Relationship

DOB

Email Address

Therapist Gender
Preference

How did You
learn about Lifeway Counseling Centers? Check all that apply.

Recommended by a Family member or Friend

Recommended by my church

Discovered through an internet search

Recommended by Physician/hospital/socialwork agency

Lifeway Minute Radio Program on 93.3 FM

LW Newsletter/Social Media

Insurance company or provider directory

Recommended by a school counselor/principal/teacher/psychologist

Other