Test Intake

Welcome to Lifeway Counseling Centers. Please complete the ‘Getting Started’ information form so that our Client Care Coordinator can call you, have an opportunity to learn a little more about your counseling needs, and schedule you for the Lifeway Consulation with a Consultation Expert.

Thank you for your interest on the information from LifeWay Counseling Centers! 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?*

Personal information

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?*

Insurance Company*

Member ID*

Group #

Upload Insurance Front Image

Upload Insurance Back Image

Responsible party for payment:

Name

Phone#

Address/Street

Organisation Name

If Family/Marriage/couples, counseling second Adult 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