Adult Client form

Gender

Marital Status

Do You Plan On Using Insurance?

Who is Counseling for

If Marriage, or family counseling 2nd person information

Describe in a few Short Sentences the reason you are looking for help from Lifeway Counseling centers ?

Describe how you believe your life will be better after working with Lifeway Counseling Staff?

How did You Discover Lifeway Counseling Centers

Recommended by a Family member or Friend

Recommended by church, synagogue

Internet Search

Recommended by Physician/hospital/social work agency

Radio, 933

Insurance company or provider directory

A school counselor/principal/teacher/psychologist

Time Slot for Interview with Lifeway: