Welcome to Life Changes Group
The following questions are intended to provide Life Changes Group with information about your treatment interests for the purpose of coordinating an initial appointment. The completion of this questionnaire is elective and does not constitute a treatment relationship with Life Changes Group and/or any of our providers. Although this information is not categorized as Protected Health Information (PHI) under HIPAA, our website offers Secure Sockets Layer (SSL), a global standard of protection that enables encrypted communication. It is utilized by millions of online businesses to decrease the risk of sensitive information from being stolen or tampered with by hackers.
Personal Information
Please complete this form for the individual(s) seeking services
Name of Client *
Date of Birth *
E-Mail Address *
Address 1 *
Address 2
City *
State *
Zipcode *
Daytime Phone *
Evening Phone
Married *
Preferred Pronoun (e.g., "he" "she" "they"...)
Please indicate for whom you are seeking services: *
Required
Additional Information
How were you referred to Life Changes Group? *
Have you or any other immediate family member ever been seen at Life Changes Group practice? *
If yes to above, please indicate the patient's name:
Have you used any mental health insurance benefits this calendar year? *
How many visits with a mental health clinician have you had this year?
Are you currently seeing any other mental health provider? *
If yes to above, please provide the name(s) and telephone number of those clinicians:
Have you ever been hospitalized for psychiatric reasons? *
If yes to above, when was the last hospitalization?
Insurance Information
Do you plan to use a health plan to pay for these services? *
Next
Never submit passwords through Google Forms.
GoogleForms
This content is neither created nor endorsed by Google.