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 appointment. Although your ISP (Internet Service Provider) is ultimately responsible for the confidentiality of information shared online, we make every reasonable effort to protect your submission in accordance with HIPAA regulations specific to behavioral healthcare. Information is only shared with our clinical team.
Personal Information
Please complete this form for the individual(s) seeking services
Name of Client *
Your answer
Date of Birth *
Your answer
E-Mail Address *
Your answer
Address 1 *
Your answer
Address 2
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Daytime Phone *
Your answer
Evening Phone
Your answer
Married *
Preferred Pronoun (e.g., "he" "she" "they"...)
Your answer
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:
Your answer
Have you used any mental health insurance benefits this calendar year? *
How many visits with a mental health clinician have you had this year?
Your answer
Are you currently seeing any other mental health provider? *
If yes to above, please provide the name(s) and telephone number of those clinicians:
Your answer
Have you ever been hospitalized for psychiatric reasons? *
If yes to above, when was the last hospitalization?
Your answer
Insurance Information
Do you plan to use a health plan to pay for these services? *
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