Lifeworks Therapy Intake Form

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Please be sure to fill out this form for every person who is seeking services.

Person Filling Out Form *

Phone Number *

Email Address *

Select "Yes" to give Lifeworks authorization to contact you at the email address listed above. Select "No" to not be contacted via email.

By selecting "Yes", you understand the following:

Although our email invoices can be sent securely, email can be intercepted, printed, and stored by others.
Lifeworks will not be liable for information lost or misdirected due to technical errors or failures.
Highly sensitive or personal information should only be communicated by email at the patient’s discretion.
You may revoke this consent in writing at any time.

Yes

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