Child/ Adolescent (For Ages 5-17)

Company

This field is for validation purposes and should be left unchanged.

Patient First / Last name

First Last

A Few Things About The Patient

Gender

Date Of Birth

Patient Marital status

Patient Mobile Phone

Address

Street Address Address Line 2 City State ZIP Code

Little Bit About Treatment

What is the reason for seeking therapy? What are you struggling with? What are your hopes and goals?

Have you ever been HOSPITALIZED for Psychiatric or Psychological problems?

Yes

If yes, please provide the year(s) you were hospitalized.

If yes, please list all medications that you are currently taking for your physical and mental wellbeing:

Have you been a previous LifeWay client?

Yes

Your Preferences

Faith Association

Would integrating Spirituality/Faith in therapy be beneficial to you?

Gender preference for therapist

Scheduling preference for initial appointment

Location preference for therapy

Payment Information

Do You Plan On Using Insurance?

Insurance Information

Primary Insurance company

Member ID

Group #

Upload Insurance Front Image

Accepted file types: jpg, png, Max. file size: 8 MB.

Upload Insurance Back Image

Accepted file types: jpg, png, Max. file size: 8 MB.

Do you have Secondary Insurance? If so, please list Insurance Company name:

Are you planning on using your Employee Assistance Program EAP?

Confirmation/ Authorization #

*If you have an EAP, it cannot be utilized until our front office has the following information: EAP Provider Authorization Number EAP Start Date and Expiration Date Number of Sessions Approved We are currently only paneled with the following EAP providers: WhiteWater Crossing Church TriHealth EAP UBH EAP Humana BH EAP Aetna EAP Cigna EAP

Who is responsible for payment?

Third Party Payor: Payment First / Last name

First Last

Payor Mobile Number

Payor relationship to patient:

Payor Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referral Information

How did you discover LifeWay?

Church /Physician/ Hospital/ School/ Agency Name

Church /Physician/ Hospital/ School/ Agency Name Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country