Get Started Form

First Name* Enter First Name

Last Name* Enter Last Name

Date Of Birth* Age should be more than 18+

Gender* Select Gender

Address* Enter Address

City* Enter City

State / Province* Select State / Province

Zip* Enter Zip code

Home Phone

Mobile Phone*

Work Phone

Email Address* Enter valid email

Reason for seeking treatment:

Desired outcome after treatment:

Doubts and fears related to treatment:

Therapist Gender Preference

Is a chronic illness (heart disease, diabetes, obesity, cancer, high blood pressure, etc.) causing any concerns that affect your wellbeing (mentally, physically, relationally, spiritually)?* Select any

Would you like LifeWay to address these concerns?

Faith Association*

Would Integrating Your Spirituality be Beneficial to you

Emergency Contact Information

Name

Phone

Relation

Do You Plan On Using Insurance?* Select any

Insurance Company*

Member ID*

Group #

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Upload Insurance Back Image

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Do you plan on using an EAP? If so, please list below:

Responsible party for payment:

Name

Phone

Address/street

Organization Name

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

Recommended by a Family member or Friend
Discovered through an internet search
Lifeway Minute Radio Program on 93.3 FM
LW Newsletter/Social Media
Insurance company or provider directory
Recommended by my church
Recommended by Physician/hospital/social work agency
Recommended by a school counselor/principal/teacher/psychologist
Other

First Name* Enter First Name

Last Name* Enter Last Name

Date Of Birth* Age should not be more than 18+

Gender* Select Gender

Address* Enter Address

City* Enter City

State / Province* Select State / Province

Zip* Enter Zip code

Home Phone

Mobile Phone*

Work Phone

Email Address* Enter valid email

Was child recommended for psychological testing?

Name of The Person Recommending

Specific type of Psychological testing if known

Parent or Guardian information

First Name* Enter First Name

Last Name* Enter Last Name

Date of Birth* Age should be more than 18+

Gender* Select Gender

Address* Enter Address

City* Enter City

State* Select State / Province

Zip* Enter Zip code

Reason for seeking treatment:

Desired outcome after treatment:

Doubts and fears related to treatment:

Therapist Gender Preference

Would you like LifeWay to address these concerns?

Faith Association*

Would Integrating Your Spirituality be Beneficial to you

Emergency Contact Information

Name

Phone

Relation

Do You Plan On Using Insurance?*

Insurance Company*

Member ID*

Group #

Upload Insurance Front Image

(JPEG or PNG)

Choose file

Upload Insurance Back Image

(JPEG or PNG)

Choose file

Do you plan on using an EAP? If so, please list below:

Responsible party for payment:

Name

Phone

Address/street

Organization Name

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

Recommended by a Family member or Friend
Discovered through an internet search
Lifeway Minute Radio Program on 93.3 FM
LW Newsletter/Social Media
Insurance company or provider directory
Recommended by my church
Recommended by Physician/hospital/social work agency
Recommended by a school counselor/principal/teacher/psychologist
Other

First Name* Enter First Name

Last Name* Enter Last Name

Date Of Birth* Enter valid DOB

Gender* Select Gender

Address* Enter Address

City* Enter City

State / Province* Select State / Province

Zip

Home Phone

Mobile Phone*

Work Phone

Email Address* Enter valid email

Reason for seeking treatment:

Desired outcome after treatment:

Doubts and fears related to treatment:

Therapist Gender Preference

Would you like LifeWay to address these concerns?

Faith Association*

Would Integrating Your Spirituality be Beneficial to you

Emergency Contact Information

Name

Phone

Relation

Do You Plan On Using Insurance?* Select any

Insurance Company*

Member ID*

Group #

Upload Insurance Front Image

(JPEG or PNG)

Choose file

Upload Insurance Back Image

(JPEG or PNG)

Choose file

Do you plan on using an EAP? If so, please list below:

Responsible party for payment:

Name*

Phone*

Address/street*

Organization Name*

If Marriage/couples, counseling second adult person information

First Name*

Last Name*

Relationship*

DOB*

Email Address*

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

Recommended by a Family member or Friend
Discovered through an internet search
Lifeway Minute Radio Program on 93.3 FM
LW Newsletter/Social Media
Insurance company or provider directory
Recommended by my church
Recommended by Physician/hospital/social work agency
Recommended by a school counselor/principal/teacher/psychologist
Other

First Name* Enter First Name

Last Name* Enter Last Name

Date Of Birth* Enter valid DOB

Gender* Select Gender

Address* Enter Address

City* Enter City

State / Province* Select State / Province

Zip

Home Phone

Mobile Phone*

Work Phone

Email Address* Enter valid email

Reason for seeking treatment:

Desired outcome after treatment:

Doubts and fears related to treatment:

Therapist Gender Preference

Would you like LifeWay to address these concerns?

Faith Association*

Would Integrating Your Spirituality be Beneficial to you

Emergency Contact Information

Name

Phone

Relation

Do You Plan On Using Insurance?* Select any

Insurance Company*

Member ID*

Group #

Upload Insurance Front Image

(JPEG or PNG)

Choose file

Upload Insurance Back Image

(JPEG or PNG)

Choose file

Do you plan on using an EAP? If so, please list below:

Responsible party for payment:

Name*

Phone*

Address/street*

Organization Name*

Is there a secondary adult who will be present for counseling?

First Name*

Last Name*

Relationship*

DOB*

Email Address*

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

Recommended by a Family member or Friend
Discovered through an internet search
Lifeway Minute Radio Program on 93.3 FM
LW Newsletter/Social Media
Insurance company or provider directory
Recommended by my church
Recommended by Physician/hospital/social work agency
Recommended by a school counselor/principal/teacher/psychologist
Other

Get Started Form

ATTENTION NEW CLIENTS: OUR ONLINE GETTING STARTED REGISTRATION SYSTEM IS DOWN FOR MAINTENANCE. PLEASE CALL OUR INTAKE LINE AT 513.744.4624 AND WE WILL BE HAPPY TO ASSIST YOU. THANK YOU!

Who will be participating in the Counseling ?*

Emergency Contact Information

Responsible party for payment:

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

Parent or Guardian information

Emergency Contact Information

Responsible party for payment:

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

Emergency Contact Information

Responsible party for payment:

If Marriage/couples, counseling second adult person information

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

Emergency Contact Information

Responsible party for payment:

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