Couples New Patient Form

Important Information About Provider/Patient Email
As a patient of LifeWay Counseling Centers, Inc., you have the right to request that we communicate with you by electronic mail (email). It is also your right to be informed in sufficient detail about the risks of communicating via email with your healthcare provider or office, and how LifeWay Counseling Centers, Inc. will use and disclose provider/patient email.

If you have an urgent or an emergency situation, call 911 or go to your nearest emergency room for treatment. Email should not be used to request assistance or to describe an urgent or emergency situation since response to emails between you and your health care provider may be hours or days apart. Email messages may be inadvertently missed, and a response is not guaranteed.

Email messages have inherent privacy risks, because they may be transmitted over many networks that are not guaranteed to be secure. Communications over the Internet and/or using the email system are usually not encrypted and are inherently insecure. You should not communicate any information with your health care provider that you wish to remain confidential.

Your email message is not a private communication between you and your doctor or therapist. Office staff at LifeWay Counseling Centers, Inc. may read your email message in order to forward or to process and respond to your email. At your healthcare provider’s discretion, your email messages and any and all responses to them may become part of your medical record.
Patient Request for Email Communications
You may request that we communicate with you via email. To do so you must understand and agree to the following terms and conditions:
- I understand LifeWay Counseling Centers, Inc. will not communicate health information that is specifically protected under state and federal law (e.g. HIV/AIDS information, substance abuse treatment records information, mental health information) via email even if we agree to communicate with you via email.
- I certify the email address provided on this request is accurate, and that I, or my designee on my behalf, accept full responsibility for messages sent to or from this address.
- acknowledge that I have received a copy of the above Important Information About Provider/Patient Email,and I have read and understand it.
- I understand and acknowledge that communications over the Internet and/or using the email system are not encrypted and are inherently insecure; that there is no assurance of confidentiality of information when communicated this way.
- I agree to hold LifeWay Counseling Centers, Inc. and individuals associated with it harmless from any and all claims and liabilities arising from or related to the Request to communicate via email.
Email address communications should be addressed:
Patient/Personal Representative Signature

By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Alcohol and Drug Abuse Assessment
Please provide a history of use for any and all following:
Alcohol
Type/Amount/Frequency/Route
Age of First Use
Date of Last Used
MM slash DD slash YYYY
Cocaine/Crack
Type/Amount/Frequency/Route
Age of First Use
Date of Last Used
MM slash DD slash YYYY
Marijuana
Type/Amount/Frequency/Route
Age of First Use
Date of Last Used
MM slash DD slash YYYY
Anti-Anxiety medicines (Valium, Xanax, Ativan etc…)
Type/Amount/Frequency/Route
Age of First Use
Date of Last Used
MM slash DD slash YYYY
Opiates Heroin, Morphine, Codeine
Type/Amount/Frequency/Route
Age of First Use
Date of Last Used
MM slash DD slash YYYY
Other Narcotics (Vicodin, OxyContin, Percocet etc…)
Type/Amount/Frequency/Route
Age of First Use
Date of Last Used
MM slash DD slash YYYY
LSD
Type/Amount/Frequency/Route
Age of First Use
Date of Last Used
MM slash DD slash YYYY
Amphetamines
Type/Amount/Frequency/Route
Age of First Use
Date of Last Used
MM slash DD slash YYYY
Inhalants
Type/Amount/Frequency/Route
Age of First Use
Date of Last Used
MM slash DD slash YYYY
Other- Includes over the counter
Type/Amount/Frequency/Route

Payment Authorization Agreement
I hereby authorize LifeWay Counseling Centers, Inc. to keep my debit or credit card information on file for payment and to initiate appropriate payment entries against the debit or credit card referenced below, as applicable, as amounts are owed by me on the Patient Account listed above. I acknowledge that the initiation of all such entries to make payments on the Patient Account listed above must comply with the provisions of U.S. law and any applicable state laws. I understand and agree that these entries may be made to my debit or credit card as applicable periodically to pay amounts owed by me on the Patient Account listed above. I also agree to notify LifeWay Counseling Centers, Inc. if my debit or credit card information changes for any reason. This authorization shall remain in effect until the "End date of authorization" listed above or until I communicate to LifeWay my intention to cancel this authorization by calling the office at 513-769-4600 or writing to LifeWay Counseling Centers, Inc. LifeWay does not charge service fees in the event of returned ACH or a declined charge; however, I understand that I will be expected to provide an alternate form of payment. I acknowledge receipt of a copy of this authorization form.
Name on Credit/Debit Card:
Select:
- Debit
- Credit
Billing Address
Street Address City State / Province / Region ZIP / Postal Code Country
Card Holder Signature

By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.
Security Code:
Card #:
Expiration Date:

Couples New Patient Form

Couples New Patient Form

Couples New Patient Form

Patient Information

Primary Care Physician/Pediatrician:

Emergency Contact:

Health Insurance/Guarantor Information

Policy Holder/Subscriber (if different from patient):

Guarantor:

LifeWay Referral Information

Authorization for Release of Confidential Information

I understand and acknowledge that without exception, information regarding scheduling, finances, or prescriptions will not be released to family members or others without my written consent in accordance with this document.

Important Information About Provider/Patient Email

Patient Request for Email Communications

Couples Questionaire

Alcohol and Drug Abuse Assessment

Alcohol

Cocaine/Crack

Marijuana

Anti-Anxiety medicines (Valium, Xanax, Ativan etc…)

Opiates Heroin, Morphine, Codeine

Other Narcotics (Vicodin, OxyContin, Percocet etc…)

LSD

Amphetamines

Inhalants

Other- Includes over the counter

Payment Authorization Agreement