Lifetime Counseling
138 Park Avenue Suite 214
Winder GA 30680-2365
678-425-9007
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LCGA-Winder
Nicole Huseman
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01-Drop2Paper
Aetna
Amerigroup Georgia
Beacon Health Options
Blue Cross Blue Shield of Georgia
Cameron and Associates
CareSource of Ohio
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CIGNA Behavioral Health
GEHA
Group Health Insurance
Humana
Magellan Behavioral Health
Multiplan
Northeast Georgia Health System
OptumHealth Behavioral Solutions
Other
TriCare for Life
TRICARE SOUTH (Humana Military) formerly known as CHAMPUS: Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee and Texas.
TriWest Healthcare Alliance
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SECONDARY INSURED ("If Applicable")
First Name
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Agender
Bigender
Cisgender Female
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MI
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MS
MO
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PA
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AE
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PR
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Occupation :
May we call at work?
Yes
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Work Hours :
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Secondary Insurance Information
CarrierName :
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0-EAP - Private Pay
0-Self Pay Client
01-Drop2Paper
Aetna
Amerigroup Georgia
Beacon Health Options
Blue Cross Blue Shield of Georgia
Cameron and Associates
CareSource of Ohio
Cenpatico Behavioral Health - Georgia
CHAMPVA
CIGNA Behavioral Health
GEHA
Group Health Insurance
Humana
Magellan Behavioral Health
Multiplan
Northeast Georgia Health System
OptumHealth Behavioral Solutions
Other
TriCare for Life
TRICARE SOUTH (Humana Military) formerly known as CHAMPUS: Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee and Texas.
TriWest Healthcare Alliance
Value Options
Wellcare of Georgia (Wellcare Provider ID is required. To obtain your provider ID, please call (866) 231-1821 option 2 then 4)
Other :
Group # :
Address :
City :
Policy # :
State :
Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
DC
WV
WI
WY
AE
CC
VI
PR
GU
SP
Zip :
Member/Subscriber # :
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US
CA
BB
SG
Phone :
Relationship :
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self
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other
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Terms And Conditions
Thank you for choosing Lifetime Counseling. Attached you will see the preregistration and required forms. Please complete the preregistration form and review all documents and electronically sign. Thank you, Lifetime Counseling
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font-family%3a sans-serif%3b transform%3a scaleX%280.996369%29%3b%22%3e%26nbsp%3b%3c/span%3e%3cspan style%3d%22left%3a 84px%3b top%3a 953.265px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996917%29%3b%22%3eEthnicity%3a %3c/span%3e%3cspan style%3d%22left%3a 84px%3b top%3a 995.515px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.998099%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 84px%3b top%3a 995.515px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.998099%29%3b%22%3eAre you currently working%3f %5b %5d Yes %5b %5d No Occupation%3a %3c/span%3e%3cspan style%3d%22left%3a 84px%3b top%3a 1037.71px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.997443%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 84px%3b top%3a 1037.71px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.997443%29%3b%22%3eWeekly Salary%3a %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %26nbsp%3b %3c/span%3e%3cspan style%3d%22left%3a 491.883px%3b top%3a 1037.71px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996758%29%3b%22%3eOther Income%3a%26nbsp%3b %3c/span%3e%3cspan style%3d%22left%3a 84px%3b top%3a 1079.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996786%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 84px%3b top%3a 1079.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996786%29%3b%22%3e1. Name of Employer%3a%26nbsp%3b %3c/span%3e%3cspan style%3d%22left%3a 84px%3b top%3a 1121.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996501%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 84px%3b top%3a 1121.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996501%29%3b%22%3e2. Employer’s address%3a %3cbr%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 84px%3b top%3a 1121.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996501%29%3b%22%3e%26nbsp%3b%3c/span%3e%3cspan style%3d%22left%3a 84px%3b top%3a 1164.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.99745%29%3b%22%3e3. How long have you been emp%3c/span%3e%3cspan style%3d%22left%3a 352.483px%3b top%3a 1164.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995774%29%3b%22%3eloyed%3a %3cbr%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 352.483px%3b top%3a 1164.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995774%29%3b%22%3e%26nbsp%3b%3c/span%3e%3cspan style%3d%22left%3a 84px%3b top%3a 1206.31px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.99895%29%3b%22%3e4. If not employed%2c are you looking for employment%3f %5b %5d Yes %5b %5d No%3c/span%3e%3cspan style%3d%22left%3a 240.033px%3b top%3a 61.4794px%3b font-size%3a 46.6px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.00615%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e5. %3cspan style%3d%22left%3a 109.64px%3b top%3a 244.381px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996224%29%3b%22%3eHow were you referred to us%3a%3c/span%3e%3cspan style%3d%22left%3a 345.083px%3b top%3a 244.381px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996017%29%3b%22%3e %3cbr%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 345.083px%3b top%3a 244.381px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996017%29%3b%22%3e%26nbsp%3b%3c/span%3e%3cspan style%3d%22left%3a 620.317px%3b top%3a 244.381px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.998773%29%3b%22%3eIf probation which office and Probation Officer%3a%3c/span%3e%3cspan style%3d%22left%3a 818.167px%3b top%3a 244.381px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996749%29%3b%22%3e %3c/span%3e%3cspan style%3d%22left%3a 114.84px%3b top%3a 286.581px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995025%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 114.84px%3b top%3a 286.581px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995025%29%3b%22%3e6. Are you an American c%3c/span%3e%3cspan style%3d%22left%3a 325.683px%3b top%3a 286.581px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.990394%29%3b%22%3eitize%3c/span%3e%3cspan style%3d%22left%3a 358.083px%3b top%3a 286.581px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.00494%29%3b%22%3en%3f %5b %5d Yes %5b %5d No %3c/span%3e%3cspan style%3d%22left%3a 550.917px%3b top%3a 286.581px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996418%29%3b%22%3ePlace of Birth%3a %3c/span%3e%3cspan style%3d%22left%3a 114.84px%3b top%3a 328.781px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.988925%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 114.84px%3b top%3a 328.781px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.988925%29%3b%22%3e7. %3c/span%3e%3cspan style%3d%22left%3a 140.24px%3b top%3a 328.781px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996206%29%3b%22%3eHighest education level completed%3a %3cbr%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 140.24px%3b top%3a 328.781px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996206%29%3b%22%3e%26nbsp%3b%3c/span%3e%3cspan style%3d%22left%3a 114.84px%3b top%3a 370.781px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995918%29%3b%22%3e8. Marital Status %28check one%29%3c/span%3e%3cspan style%3d%22left%3a 135.04px%3b top%3a 391.981px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996973%29%3b%22%3e%5b %5d Single%3c/span%3e%3cspan style%3d%22left%3a 384.083px%3b top%3a 391.981px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.99635%29%3b%22%3e%5b %5d Married%2c how long%3f%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e%3cspan style%3d%22left%3a 135.04px%3b top%3a 412.981px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996771%29%3b%22%3e%5b %5d Divorced %3c/span%3e%3cspan style%3d%22left%3a 384.083px%3b top%3a 412.981px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996805%29%3b%22%3e%5b %5d Separated%2c how long%3f%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e%3cspan style%3d%22left%3a 135.04px%3b top%3a 434.231px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.99592%29%3b%22%3e%5b %5d Widow/Widower%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 135.04px%3b top%3a 434.231px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.99592%29%3b%22%3e%26nbsp%3b%3c/span%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 476.231px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995761%29%3b%22%3e9.%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 476.231px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996275%29%3b%22%3eHow many times have you been married%3f %3c/span%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 508.031px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 508.031px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e10.%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 508.031px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995694%29%3b%22%3eHow many persons are currently living with you%3f %3c/span%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 539.631px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.05237%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 539.631px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.05237%29%3b%22%3e11.%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 539.631px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996458%29%3b%22%3ePlease list ages and genders of all your children/step%3c/span%3e%3cspan style%3d%22left%3a 573.317px%3b top%3a 539.631px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b%22%3e-%3c/span%3e%3cspan style%3d%22left%3a 579.517px%3b top%3a 539.631px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.993679%29%3b%22%3echildren%3a %3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 579.517px%3b top%3a 539.631px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.993679%29%3b%22%3e%26nbsp%3b%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 571.231px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996749%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 184.833px%3b top%3a 571.231px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996749%29%3b%22%3e%26nbsp%3b%3c/span%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 602.831px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e12.%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 602.831px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995874%29%3b%22%3eMy general health is%3a %28Check one%29 %5b %5d Good %5b %5d Fair %5b %5d Poor%3c/span%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 634.431px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 634.431px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e13.%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 634.431px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996139%29%3b%22%3eI have the following medical problems%3a %28Check all that apply%29%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 634.431px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996139%29%3b%22%3e%26nbsp%3b%3c/span%3e%3cspan style%3d%22left%3a 174.033px%3b top%3a 666.031px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996546%29%3b%22%3e%5b %5d Stomach %3c/span%3e%3cspan style%3d%22left%3a 424.883px%3b top%3a 666.031px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.00151%29%3b%22%3e%5b %3c/span%3e%3cspan style%3d%22left%3a 445.283px%3b top%3a 666.031px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.997532%29%3b%22%3e%5d Diabetes%3c/span%3e%3cspan style%3d%22left%3a 684.117px%3b top%3a 666.031px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995351%29%3b%22%3e%5b %5d Back%3c/span%3e%3cspan style%3d%22left%3a 174.033px%3b top%3a 697.631px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995854%29%3b%22%3e%5b %5d Heart%3c/span%3e%3cspan style%3d%22left%3a 424.883px%3b top%3a 697.631px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995984%29%3b%22%3e%5b %5d Headaches/Migraines%3c/span%3e%3cspan style%3d%22left%3a 684.117px%3b top%3a 697.631px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995107%29%3b%22%3e%5b %5d Liver%3c/span%3e%3cspan style%3d%22left%3a 174.033px%3b top%3a 729.265px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.997054%29%3b%22%3e%5b %5d High Blood Pressure%3c/span%3e%3cspan style%3d%22left%3a 424.883px%3b top%3a 729.265px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.997373%29%3b%22%3e%5b %5d Sleeping Difficulties%3c/span%3e%3cspan style%3d%22left%3a 684.117px%3b top%3a 729.265px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996731%29%3b%22%3e%5b %5d Other %3c/span%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 760.865px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 760.865px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e14.%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 760.865px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.99604%29%3b%22%3eI take/ or have taken the following medications in the last six months%3a%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 792.665px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996749%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 792.665px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996749%29%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 887.465px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e15.%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 887.465px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995068%29%3b%22%3eOver the past month%2c I have felt%3a %28Circle all that apply%29%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 919.065px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995549%29%3b%22%3e%26nbsp%3b%26nbsp%3b Nervous%2c %3c/span%3e%3cspan style%3d%22left%3a 264.033px%3b top%3a 919.065px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.99776%29%3b%22%3eSad%3c/span%3e%3cspan style%3d%22left%3a 384.083px%3b top%3a 919.065px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.998129%29%3b%22%3e%2c Depressed%3c/span%3e%3cspan style%3d%22left%3a 564.117px%3b top%3a 919.065px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.998347%29%3b%22%3e%2c Angry%2c %3c/span%3e%3cspan style%3d%22left%3a 684.117px%3b top%3a 919.065px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.997797%29%3b%22%3eContent%3c/span%3e%3cspan style%3d%22left%3a 804.167px%3b top%3a 919.065px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.998229%29%3b%22%3e%2c Apathetic%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 950.665px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.997094%29%3b%22%3e%2c Happy%2c %3c/span%3e%3cspan style%3d%22left%3a 264.033px%3b top%3a 950.665px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995125%29%3b%22%3eExcited%2c %3c/span%3e%3cspan style%3d%22left%3a 384.083px%3b top%3a 950.665px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.01921%29%3b%22%3eTired%2c %3c/span%3e%3cspan style%3d%22left%3a 564.117px%3b top%3a 950.665px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.9986%29%3b%22%3eOther%3a %3c/span%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 982.265px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 982.265px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e16.%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 982.265px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.03003%29%3b%22%3eToday%2c I feel%3a%3c/span%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 1015.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22left%3a 114.04px%3b top%3a 1015.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996156%29%3b%22%3e17.%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 1015.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996516%29%3b%22%3eI am interested %3c/span%3e%3cspan style%3d%22left%3a 270.633px%3b top%3a 1015.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996011%29%3b%22%3ein the following types of counseling%3a %3c/span%3e%3cspan style%3d%22left%3a 564.317px%3b top%3a 1013.95px%3b font-size%3a 20px%3b font-family%3a sans-serif%3b%22%3e%28%3c/span%3e%3cspan style%3d%22left%3a 570.917px%3b top%3a 1015.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b%22%3eC%3c/span%3e%3cspan style%3d%22left%3a 584.117px%3b top%3a 1015.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995684%29%3b%22%3eircle all that apply%29%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 1048.51px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.994405%29%3b%22%3e Individual%2c %3c/span%3e%3cspan style%3d%22left%3a 264.033px%3b top%3a 1048.51px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996705%29%3b%22%3eMarriage and Family%2c %3c/span%3e%3cspan style%3d%22left%3a 490.083px%3b top%3a 1048.51px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.993469%29%3b%22%3eGroup%3a %3c/span%3e%3cspan style%3d%22left%3a 592.117px%3b top%3a 1048.51px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995947%29%3b%22%3eSubstance Abuse%2c%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 1080.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.997297%29%3b%22%3e Anger Management%2c %3c/span%3e%3cspan style%3d%22left%3a 361.283px%3b top%3a 1080.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.0054%29%3b%22%3eValues Clarification%2c %3c/span%3e%3cspan style%3d%22left%3a 744.367px%3b top%3a 1080.11px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.998771%29%3b%22%3eDomestic Violence%2c%3c/span%3e%3cspan style%3d%22left%3a 294.233px%3b top%3a 1111.71px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996287%29%3b%22%3e %3c/span%3e%3cspan style%3d%22left%3a 415.683px%3b top%3a 1111.71px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.993371%29%3b%22%3ePTSD/Military%2c %3c/span%3e%3cspan style%3d%22left%3a 532.517px%3b top%3a 1111.71px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996568%29%3b%22%3eIndividual/Family%2c %3c/span%3e%3cspan style%3d%22left%3a 725.367px%3b top%3a 1111.71px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996594%29%3b%22%3eGrief Counseling%2c%3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 1143.31px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996779%29%3b%22%3e Adolescent Substance Abuse Prevention%2c %3c/span%3e%3cspan style%3d%22left%3a 522.517px%3b top%3a 1143.31px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996744%29%3b%22%3eParenting%2c Bulling Awareness%2c %3c/span%3e%3cspan style%3d%22left%3a 148.84px%3b top%3a 1174.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.0004%29%3b%22%3eWorkplace Diversity/Ethics Training%2c %3c/span%3e%3cspan style%3d%22left%3a 478.483px%3b top%3a 1174.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995303%29%3b%22%3eAdolescent %3c/span%3e%3cspan style%3d%22left%3a 574.117px%3b top%3a 1174.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.995682%29%3b%22%3e/Child %3c/span%3e%3cspan style%3d%22left%3a 626.117px%3b top%3a 1174.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.99406%29%3b%22%3eBehavioral %3c/span%3e%3cspan style%3d%22left%3a 717.767px%3b top%3a 1174.91px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.997684%29%3b%22%3eDevelopment%2c %3c/span%3e%3cspan style%3d%22left%3a 144.04px%3b top%3a 1206.51px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%281.00292%29%3b%22%3eTelephone/Online Counseling%2c %3c/span%3e%3cspan style%3d%22left%3a 499.917px%3b top%3a 1206.51px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.99315%29%3b%22%3eStress %3c/span%3e%3cspan style%3d%22left%3a 556.917px%3b top%3a 1206.51px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.993183%29%3b%22%3e/Anxiety %3c/span%3e%3cspan style%3d%22left%3a 627.117px%3b top%3a 1206.51px%3b font-size%3a 18.4px%3b font-family%3a sans-serif%3b transform%3a scaleX%280.996249%29%3b%22%3eManagement or Other%3a %3c/span%3e%3c/p%3e%3cdiv id%3d%22outerContainer%22%3e%3cdiv id%3d%22mainContainer%22%3e%3cdiv id%3d%22viewerContainer%22 tabindex%3d%220%22%3e %3c/div%3e %3c/div%3e %3c/div%3e
Electronic Signature of Client or Legal Guardian:
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I have read and I agree to the
Personal History
Release Of Information
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%3cp style%3d%22text-align%3a center%3b%22 align%3d%22center%22%3e%3cspan style%3d%22font-size%3a 8pt%3b font-family%3a Arial%2c sans-serif%3b%22%3eLIFETIME COUNSELING%3cbr%3e%3c/span%3e%3c/p%3e%3cp style%3d%22text-align%3a center%3b%22 align%3d%22center%22%3e%3cspan style%3d%22font-size%3a 8pt%3b font-family%3a Arial%2c sans-serif%3b%22%3e138 Park Avenue Suite 214 Winder%2c GA 30680%3c/span%3e%3c/p%3e%3cp style%3d%22text-align%3a center%3b%22 align%3d%22center%22%3e%3cspan style%3d%22font-size%3a 8pt%3b font-family%3a Arial%2c sans-serif%3b%22%3e%28678%29 425-9007 Fax %28678%29 425-9009%3c/span%3e%3c/p%3e%3cp style%3d%22text-align%3a center%3b%22 align%3d%22center%22%3e%3cspan style%3d%22font-size%3a 8pt%3b font-family%3a Arial%2c sans-serif%3b%22%3ewww.Lifetimecounseling.com%3cspan%3e%26nbsp%3b %3c/span%3e%3c/span%3e%3ca href%3d%22mailto%3aLifetimecounseling@gmail.com%22%3e%3cspan style%3d%22font-size%3a 8pt%3b font-family%3a Arial%2c sans-serif%3b%22%3eLifetimecounseling@gmail.com%3c/span%3e%3c/a%3e%3c/p%3e%3cp style%3d%22text-align%3a center%3b%22 align%3d%22center%22%3e%3cspan style%3d%22font-size%3a 8pt%3b font-family%3a Arial%2c sans-serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-family%3a Times New Roman%2c serif%3b%22%3eCONSENT AND AUTHORIZATION TO RELEASE INFORMATION OR MEDICAL RECORDS UNDER THE PROTECTION OF FEDERAL LAW TITLE 42 CFR%2c CHAPTER 11%2c PART II.%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eNAME%3a _________________________________________%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%3c/span%3eDOB%3a____________________%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eI%2c the above mentioned%2c authorize Lifetime Counseling Center%2c Inc. to release/obtain information to the facilities/persons listed below by mode of%3a%3cspan%3e%26nbsp%3b %3c/span%3eFax%2c Phone%2c Personal Conference%2c or Copies%2c that may be needed to treat me more effectively.%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eTo%3a%3cspan%3e%26nbsp%3b %3c/span%3eFacility/Person__________________________________________%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3ePhone%3a __________________%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eAddress%3a _____________________________________________________________________________%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eDate of Service%3a __________________%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eInformation to be sent%3a%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e___ Results of psychological testing%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e___ Discharge Summary%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e___ MMPI profile%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e___ Recommendation for current therapy%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e___ Medication%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e___ Domestic Violence Orientation%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e___ Diagnosis%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e___ Anger Management Evaluation%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e___ Statement of Progress%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e___ Substance Abuse Evaluation%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e___ School records%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e___ Psychosocial Evaluation%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e___ Other%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eTo be used for the purpose of%3a _________________________________________________________%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e__________________________________________________________________________________%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e“This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulation %2842%2c CRF%2c Part II%29 prohibit you from making any further disclosures of it without the specific written consent of the person to whom it pertains%2c or as otherwise permitted by such regulation. A general authorization for the release of medical or other information is not sufficient for this purpose.”%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eThis authorization to release/receive information shall be effective for twelve months. You may terminate this authorization%2c however%2c at any time except to the extent that the program or person making the disclosure has already acted in reliance upon it.%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eI hereby release Lifetime Counseling Center%2c Inc. from all legal liability that might arise from the release of information requested. I consider a photocopy of this authorization to be as valid as the original.%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e_________________________________%3cspan%3e%26nbsp%3b %3c/span%3e_________%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e_____________________________%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e______%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eClient%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3eDate%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3eParent/Legal Guardian %28relationship%29%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3eDate%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e________________________________%3cspan%3e%26nbsp%3b %3c/span%3e_________%3c/span%3e%3c/p%3e%3cp%3e%3cspan style%3d%22font-size%3a 11pt%3b font-family%3a Times New Roman%2c serif%3b%22%3eWitness%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3eDate%3c/span%3e%3c/p%3e
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Electronic Signature of Client or Legal Guardian:
Date:
I have read and I agree to the
Release Of Information
Informed Consent
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%3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%3cspan style%3d%22font-family%3a%26quot%3bArial%26quot%3b%2csans-serif%22%3eLIFETIME COUNSELING%3cbr%3e%3c/span%3e%3c/p%3e%3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%3cspan style%3d%22font-family%3a%26quot%3bArial%26quot%3b%2csans-serif%22%3e138 Park Avenue Suite 214 Winder%2c GA 30680%3c/span%3e%3c/p%3e %3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%3cspan style%3d%22font-family%3a%26quot%3bArial%26quot%3b%2csans-serif%22%3e%28678%29 425-9007 Fax %28678%29 425-9009%3c/span%3e%3c/p%3e %3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%3cspan style%3d%22font-family%3a%26quot%3bArial%26quot%3b%2csans-serif%22%3ewww.Lifetimecounseling.com%3cspan style%3d%22mso-spacerun%3ayes%22%3e%26nbsp%3b %3c/span%3e%3ca href%3d%22mailto%3aLifetimecounseling@gmail.com%22%3eLifetimecounseling@gmail.com%3c/a%3e %3c/span%3e%3c/p%3e %3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%3ci%3e%26nbsp%3b%3c/i%3e%3c/p%3e %3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%3ci%3eABOUT OUR SERVICES%3c/i%3e…%3c/p%3e %3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22%3eIn order to provide you with our services%2c we need your consent in writing.%3cspan style%3d%22mso-spacerun%3ayes%22%3e%26nbsp%3b %3c/span%3eThis consent will enable us to treat you in a responsible manner and keep all information confidential to ensure your privacy in accordance with O.C.G.A. 37-7-2%2c 40-5-1%2c and 40-5-631.%3c/p%3e %3cp class%3d%22MsoNormal%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22%3eI understand that the information and records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records%2c 42 CFR Part 2%2c and may not be disclosed without my written consent%2c with the exception of medical emergency%2c or if we feel you are about to harm yourself or others%2c or have committed a previously undisclosed crime which we are required to report to DFACS or other authorities.%3c/p%3e %3cp class%3d%22MsoNormal%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22%3ePsychotherapy may involve the risk of remembering unpleasant events and discussing sensitive issues.%3cspan style%3d%22mso-spacerun%3ayes%22%3e%26nbsp%3b %3c/span%3eI understand that this process is intended to help me better cope with life situations and to experience growth as a person.%3c/p%3e %3cp class%3d%22MsoNormal%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%3ci%3eABOUT YOUR PAYMENT%3c/i%3e…%3c/p%3e %3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22%3ePayment is expected at the time of service unless other arrangements have been made.%3cspan style%3d%22mso-spacerun%3ayes%22%3e%26nbsp%3b %3c/span%3eCo-payment is required at the time of service if you are using insurance.%3cspan style%3d%22mso-spacerun%3ayes%22%3e%26nbsp%3b %3c/span%3eYou will be responsible for payment if we are filing insurance for you and the insurance carrier does not pay the full amount charged.%3c/p%3e %3cp class%3d%22MsoNormal%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%3ci%3eABOUT YOUR APPOINTMENT%3c/i%3e…%3c/p%3e %3cp class%3d%22MsoNormal%22 style%3d%22text-align%3acenter%22 align%3d%22center%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22%3eA notice of 24 hours must be given if you are unable to keep your appointment.%3cspan style%3d%22mso-spacerun%3ayes%22%3e%26nbsp%3b %3c/span%3eOtherwise%2c you will be charged a %2425.00 rescheduling fee.%3c/p%3e %3cp class%3d%22MsoNormal%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22%3eI have read the above and understand that I will not receive services from Lifetime Counseling%2c LLC without consent%2c and that I am responsible for all payments of services rendered by Lifetime Counseling%2c LLC.%3c/p%3e %3cp class%3d%22MsoNormal%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22MsoNormal%22%3eClient Signature%3a___________________________%3cspan style%3d%22mso-spacerun%3ayes%22%3e%26nbsp%3b %3c/span%3eDate%3a__________________________%3c/p%3e %3cp class%3d%22MsoNormal%22%3e%26nbsp%3b%3c/p%3e
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Electronic Signature of Client or Legal Guardian:
Date:
I have read and I agree to the
Informed Consent
HIPPA
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%3cdiv%3e %3cp%3e%3cspan style%3d%22font-family%3a Arial%2c sans-serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e %3cdiv%3e %3cp%3e%3cspan style%3d%22font-family%3a Arial%2c sans-serif%3b%22%3e%26nbsp%3b%3c/span%3e%3c/p%3e %3ctable style%3d%22border%3a medium none%3b%22 width%3d%22581%22 cellspacing%3d%220%22 cellpadding%3d%220%22 border%3d%221%22 align%3d%22left%22%3e %3ctbody%3e%3ctr%3e %3ctd style%3d%22width%3a 6.05in%3b padding%3a 0in%3b border-style%3a solid%3b border-width%3a 1pt 4.5pt 4.5pt 1pt%3b text-align%3a left%3b%22 width%3d%22581%22 valign%3d%22top%22%3e %3cp class%3d%22ln%22%3eHIPAA Notice of Privacy Practices and HIV / AIDS Guidelines%3c/p%3e %3c/td%3e %3c/tr%3e %3c/tbody%3e%3c/table%3e %3cp%3e%26nbsp%3b%3c/p%3e %3ctable style%3d%22border%3a medium none%3b%22 width%3d%22581%22 cellspacing%3d%220%22 cellpadding%3d%220%22 border%3d%221%22%3e %3ctbody%3e%3ctr%3e %3ctd style%3d%22width%3a 6.05in%3b padding%3a 4.3pt 0in%3b border-style%3a solid solid none%3b border-width%3a 1pt 1pt medium%3b text-align%3a left%3b%22 width%3d%22581%22 valign%3d%22top%22%3e %3cp class%3d%22lb%22%3eThis notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.%3c/p%3e %3c/td%3e %3c/tr%3e %3ctr%3e %3ctd style%3d%22width%3a 6.05in%3b padding%3a 4.3pt 0in%3b border-style%3a none solid%3b border-width%3a medium 1pt%3b text-align%3a left%3b%22 width%3d%22581%22 valign%3d%22top%22%3e %3ch3%3eUnderstanding Your Protected Health Information %28PHI%29%3c/h3%3e %3cp style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eWhen you visit us%2c a record is made of you including symptoms%2c examinations%2c test results%2c impressions%2c treatment plan%2c and other mental health or medical information. Your record is the physical property of Lifetime Counseling%2c LLC. The information within belongs to you. Being aware of what is in your record will help you to make more informed decisions when authorizing disclosures to others. In using and disclosing your PHI%2c it is our objective to follow the Privacy Standards of the Federal Health Insurance Portability and Accountability Act %28HIPAA%29 and requirement of state law.%3c/span%3e%3c/p%3e %3ch3%3eYour Mental Health and/or Medical Record Serves as%3a%3c/h3%3e %3cp%3e•%3cspan style%3d%22font-size%3a 10pt%3b%22%3e%3cspan%3e %3c/span%3eA basis for planning your care and treatment.%3c/span%3e%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eA means of communication among the health professionals who may contribute to your care.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eA legal document describing the care you received.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eA means by which you or a third-party payer can verify that services billed were actually provided.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eA source of information for public health officials charged with improving the health of the nation.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eA source of data for facility planning and marketing.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eA tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.%3c/p%3e %3ch3%3eGeorgia State Laws and Guidelines Regarding HIV / AIDS%3c/h3%3e %3cp style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eGeorgia statutory law defines AIDS Confidential Information %28ACI%29 and makes the confidentiality requirements for the disclosure of ACI more stringent than those for other medical records. A patient%27s written consent is required to disclose ACI unless the disclosure is otherwise authorized or required by law. %3cbr%3e %3cbr%3e %3cb%3e%3ci%3eAIDS Confidential Information%3c/i%3e%3c/b%3e is defined as information that a person%3a %3c/span%3e%3c/p%3e %3col%3e%3cli style%3d%22text-align%3a left%3b%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3ehas been diagnosed as having AIDS%3b %3c/span%3e%3c/li%3e%3cli style%3d%22text-align%3a left%3b%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3ehas been or is being treated for AIDS%3b %3c/span%3e%3c/li%3e%3cli style%3d%22text-align%3a left%3b%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3ehas been determined to be infected with HIV%3b %3c/span%3e%3c/li%3e%3cli style%3d%22text-align%3a left%3b%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3ehas submitted to an HIV test%3b %3c/span%3e%3c/li%3e%3cli style%3d%22text-align%3a left%3b%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3ehas had a positive or negative result from an HIV antibody test%3b %3c/span%3e%3c/li%3e%3cli style%3d%22text-align%3a left%3b%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3ehas sought and received counseling regarding HIV/AIDS%3b or %3c/span%3e%3c/li%3e%3cli style%3d%22text-align%3a left%3b%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3ehas been determined to be a person at risk of being infected with HIV.%3cbr%3e %28O.C.G.A. 24-9-47 and 31-22-9.1%29 %3c/span%3e%3c/li%3e%3c/ol%3e %3cp class%3d%22bl2i%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22bl2i%22%3e%3cb%3eHIV Infected Person%27s Self-Disclosure to Partners %3c/b%3e%3c/p%3e %3cp class%3d%22bl2i%22%3eHIV-infected people are legally required to disclose their infection status to another person prior to engaging in sexual activity or sharing injection drug needles with that person. %28O.C.G.A. 16-5-60%29%3c/p%3e %3ch3%3eResponsibilities of Lifetime Counseling%3c/h3%3e %3cp style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eWe are required to%3a%3c/span%3e%3c/p%3e %3cp class%3d%22bl%22%3e•%3cspan%3e %3c/span%3eMaintain the privacy of your PHI as required by law and provide you with notice of legal duties and privacy practices with respect to the PHI that we collect and maintain about you.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eAbide by the terms of this notice currently in effect. We have the right to change our notice of privacy practices and to make the new provisions effective for all protected health information that we maintain%2c including that obtained prior to the change. Should our information practices change%2c we will post new changes in the reception room and provide you with a copy.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eNotify you if we are unable to agree to a requested restriction.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eUse or disclose your health information only with your authorization except as described in this notice.%3c/p%3e %3ch3%3eYour Protected Health Information %28PHI%29 Rights%3c/h3%3e %3cp style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eYou have the right to%3a%3c/span%3e%3c/p%3e %3cp class%3d%22bl%22%3e•%3cspan%3e %3c/span%3eReview and obtain a paper copy of the notice of information practices and your health information upon request. A few exceptions apply. Copy charges may apply.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eRequest and provide written authorization and permission to release PHI for purposes of outside treatment and health care. This authorization excludes psychotherapy notes and any audio/video tapes that may have been made with your permission for training purposes.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eRevoke your authorization in writing at any time to use%2c disclose%2c or restrict health information except to the extent that action has already been taken.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eRequest a restriction on certain uses and disclosures of PHI%2c but we are not required to agree to the restriction request. You should address your restriction in writing to the Privacy Officer by asking for name of Privacy Officer%2c address%2c and phone. We will notify you within 10 days if we cannot agree to the restriction.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eRequest that we amend your health information by submitting a written request with reasons supporting the request to the Privacy Officer. We are not required to agree with the requested amendment.%3c/p%3e %3cp class%3d%22bl2i%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22bl2i%22%3e%26nbsp%3b%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eObtain an accounting of disclosures of your health information for purposes other than treatment%2c payment%2c health care operations%2c and certain other activities for the past six years but not before %3c/p%3e %3cp class%3d%22bl2i%22%3e%3cspan%3e %3c/span%3eApril 14%2c 2003.%3c/p%3e %3cp class%3d%22bl2i%22%3e•%3cspan%3e %3c/span%3eRequest confidential communications of your health information by alternative means or at alternative locations.%3c/p%3e %3cp class%3d%22bl2i%22%3eDisclosures for Treatment%2c Payment%2c and Health Operations%3c/p%3e %3cp style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eLifetime Counseling will use your PHI%2c with your consent%2c in the following circumstances%3a%3c/span%3e%3c/p%3e %3cp class%3d%22unl%22 style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cu%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eTreatment%3c/span%3e%3c/u%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 12pt%3b%22%3e%3a Information obtained by a nurse%2c physician%2c psychologist/counselor%2c dentist%2c or other member of your health care team will be recorded in your record and used to determine the management and coordination of treatment that will be provided for you.%3c/span%3e%3c/span%3e%3c/p%3e %3cp class%3d%22unl%22 style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cu%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eDisclosure to others outside of the agency%3c/span%3e%3c/u%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3e%3a%3c/span%3e%3c/span%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 12pt%3b font-family%3a Arial Unicode MS%3b%22%3e %3c/span%3e%3c/span%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 12pt%3b%22%3eIf you give us written authorization%2c you may revoke it in writing at any time but that revocation will not affect any use or disclosures permitted by your authorization while it was in effect. We will not use or disclose your health information without your authorization%2c except to report a serious threat to the health or safety of a child and/or vulnerable adult.%3c/span%3e%3c/span%3e%3c/p%3e %3cp class%3d%22unl%22 style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cu%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eFor payment%2c if applicable%3c/span%3e%3c/u%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3e%3a%3c/span%3e%3c/span%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 12pt%3b font-family%3a Arial Unicode MS%3b%22%3e %3c/span%3e%3c/span%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 12pt%3b%22%3eWe may send a bill to you or to your insurance carrier. The information on or accompanying the bill may include information that identifies you%2c as well as your diagnosis to obtain reimbursement for your health care or to determine eligibility or coverage.%3c/span%3e%3c/span%3e%3c/p%3e %3cp class%3d%22unl%22 style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cu%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eFor health care operations%3c/span%3e%3c/u%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3e%3a%3c/span%3e%3c/span%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 12pt%3b font-family%3a Arial Unicode MS%3b%22%3e %3c/span%3e%3c/span%3e%3cspan class%3d%22unl10ptChar%22%3e%3cspan style%3d%22font-size%3a 12pt%3b%22%3eMembers of the mental health staff or members of the quality improvement team may use the information in your health record to assess the performance and operations of our services. This information will be used in an effort to continually improve the quality and effectiveness of the mental health care and services we provide.%3c/span%3e%3c/span%3e%3c/p%3e %3cp class%3d%22unl%22 style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cspan style%3d%22font-size%3a 12pt%3b%22%3eWe may use or disclose your PHI in the following situations without your authorization%3a as required by law%2c public health issues as required by law%2c communicable diseases%2c health oversight%2c abuse/neglect%2c Food and Drug Administration requirements%2c legal proceedings%2c law enforcement%2c coroners and organ donation%2c research%2c or workers’ compensation. Under the law%2c we must make disclosures to you when required by the Secretary of the U.S. Department of Health and Human Services to investigate or determine our compliance with the requirements.%3c/span%3e%3c/p%3e %3ch3%3eFor More Information or to Report a Problem%3c/h3%3e %3cp style%3d%22text-align%3a left%3b%22 align%3d%22left%22%3e%3cspan style%3d%22font-size%3a 12pt%3b%22%3eIf you have questions and would like additional information%2c please ask your clinician. He/she will provide you with additional information or put you in contact with the designated Privacy Officer. If you are concerned that your privacy rights have been violated or you disagree with a decision we have made about access to your health information%2c you may contact the Privacy Officer. We respect your right to privacy of your health information. There will be no retaliation in any way for filing a complaint with the Privacy Officer of our agency or the U.S. Department of Health and Human Services.%3c/span%3e%3c/p%3e %3c/td%3e %3c/tr%3e %3ctr%3e %3ctd style%3d%22width%3a 6.05in%3b padding%3a 4.3pt 0in%3b border-style%3a none solid solid%3b border-width%3a medium 1pt 1pt%3b text-align%3a left%3b%22 width%3d%22581%22 valign%3d%22top%22%3e %3ch3%3e%3c/h3%3e %3c/td%3e %3c/tr%3e %3c/tbody%3e%3c/table%3e %3c/div%3e %3cspan style%3d%22font-size%3a 12pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%3cbr clear%3d%22all%22%3e %3c/span%3e %3cdiv%3e %3ctable style%3d%22border%3a medium none%3b%22 cellspacing%3d%220%22 cellpadding%3d%220%22 border%3d%221%22%3e %3ctbody%3e%3ctr%3e %3ctd style%3d%22width%3a 6.05in%3b padding%3a 0in%3b border-style%3a solid%3b border-width%3a 1pt 4.5pt 4.5pt 1pt%3b text-align%3a left%3b%22 width%3d%22581%22 valign%3d%22top%22%3e %3cp class%3d%22ln%22%3eHIPAA Privacy Authorization for Use and%3cbr%3e Disclosure of Personal Health Information%3c/p%3e %3c/td%3e %3c/tr%3e %3c/tbody%3e%3c/table%3e %3cp%3e%26nbsp%3b%3c/p%3e %3ctable style%3d%22border%3a medium none%3b%22 width%3d%22581%22 cellspacing%3d%220%22 cellpadding%3d%220%22 border%3d%221%22%3e %3ctbody%3e%3ctr%3e %3ctd style%3d%22width%3a 6.05in%3b padding%3a 4.3pt 0in%3b border-style%3a solid%3b border-width%3a 1pt%3b text-align%3a left%3b%22 width%3d%22581%22 valign%3d%22top%22%3e %3cp class%3d%22lb%22%3eThis authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 %28HIPAA%29 and its implementing regulations as amended from time to time.%3cbr%3e You may refuse to sign this authorization.%3c/p%3e %3cp class%3d%22Before12pt%22%3eBy my signature below%2c I acknowledge that I have received and read the Notice of Health Information Privacy Practices. I have been provided a copy of%2c read and understand Lifetime Counseling HIPAA Privacy Notice containing a complete description of my rights%2c and the permitted uses and disclosures of my protected health information under HIPAA. Further%2c I acknowledge that any information used or disclosed pursuant to this authorization could be at risk for re-disclosure by the recipient and is no longer protected under HIPAA.%3c/p%3e %3cp class%3d%22Before12pt%22%3e%3cu%3e%3cspan%3e %3c/span%3e%3c/u%3e%3cspan%3e %3c/span%3e%3cu%3e%3cspan%3e %3c/span%3e%3c/u%3e%3c/p%3e %3cp%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eClient Signature%3cspan%3e %3c/span%3eDate%3c/span%3e%3c/p%3e %3cp style%3d%22text-align%3a center%3b%22 align%3d%22center%22%3e%3cb%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eFor office use only%3c/span%3e%3c/b%3e%3c/p%3e %3cp class%3d%22Before12pt%22%3eI attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices%2c but acknowledgment could not be obtained.%3c/p%3e %3cp class%3d%22Before12pt%22%3eReason%3a%3cspan style%3d%22font-family%3a Arial Unicode MS%3b%22%3e %3c/span%3e%3cu%3e%3cspan%3e %3c/span%3e%3c/u%3e%3c/p%3e %3cp class%3d%22Before12pt%22%3e%3cu%3e%3cspan%3e %3c/span%3e%3c/u%3e%3cspan%3e %3c/span%3e%3cu%3e%3cspan%3e %3c/span%3e%3c/u%3e%3c/p%3e %3cp%3e%3cspan style%3d%22font-size%3a 10pt%3b%22%3eClinician Signature%3cspan%3e %3c/span%3eDate%3c/span%3e%3c/p%3e %3cp class%3d%22Normalw12ptsabove%22%3e%26nbsp%3b%3c/p%3e %3c/td%3e %3c/tr%3e %3c/tbody%3e%3c/table%3e %3c/div%3e %3cspan style%3d%22font-size%3a 12pt%3b font-family%3a Times New Roman%2c serif%3b%22%3e%3cbr clear%3d%22all%22%3e %3c/span%3e %3cp%3e%26nbsp%3b%3c/p%3e %3c/div%3e
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Electronic Signature of Client or Legal Guardian:
Date:
I have read and I agree to the
HIPPA
COVID-19
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%3cp style%3d%22text-align%3a center%3b%22 align%3d%22center%22%3e%3cb%3e%3cu%3e%3cspan style%3d%22font-size%3a 15pt%3b%22%3eAssumption of the Risk and Waiver of Liability Relating to%3c/span%3e%3c/u%3e%3c/b%3e%3c/p%3e %3cp style%3d%22text-align%3a center%3b%22 align%3d%22center%22%3e%3cb%3e%3cu%3e%3cspan style%3d%22font-size%3a 15pt%3b%22%3eCoronavirus/COVID-19%3c/span%3e%3c/u%3e%3c/b%3e%3c/p%3e %3cp%3e%26nbsp%3b%3c/p%3e %3cp style%3d%22text-align%3a justify%3b%22%3e%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3eThe novel coronavirus%2c COVID-19%2c has been declared a worldwide pandemic by the World Health Organization.%3cspan%3e%26nbsp%3b %3c/span%3e%3cb%3eCOVID-19 is extremely contagious%3c/b%3e and is believed to spread mainly from person-to-person contact.%3cspan%3e%26nbsp%3b %3c/span%3eAs a result%2c federal%2c state%2c and local governments and federal and state health agencies recommend social distancing and have%2c in many locations%2c prohibited the congregation of groups of people. %3c/p%3e %3cp style%3d%22text-align%3a justify%3b%22%3e%26nbsp%3b%3c/p%3e %3cp style%3d%22text-align%3a justify%3b%22%3e%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3eLifetime Counseling%2c has put in place preventative measures to reduce the spread of COVID-19%3b however%2c Lifetime Counseling %3cb%3ecannot guarantee%3c/b%3e that you or your child%28ren%29 will not become infected with COVID-19.%3cspan%3e%26nbsp%3b %3c/span%3eFurther%2c attending in-person appointments with Lifetime Counseling %3cb%3ecould %3cu%3eincrease%3c/u%3e%3c/b%3e your risk and your child%28ren%29’s risk of contacting COVID-19.%3cspan%3e%26nbsp%3b %3c/span%3e%3c/p%3e %3cdiv style%3d%22padding%3a 0in 0in 1pt%3b border-style%3a none none dotted%3b border-width%3a medium medium 3pt%3b%22%3e %3cp style%3d%22padding%3a 0in%3b border-style%3a none%3b border-width%3a medium%3b border-image%3a none 100%25 / 1 / 0 stretch%3b%22%3e%26nbsp%3b%3c/p%3e %3c/div%3e %3cp%3e%26nbsp%3b%3c/p%3e %3cp style%3d%22text-align%3a justify%3b%22%3eBy signing this agreement%2c I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that myself and/or my child%28ren%29 may be exposed to or infected by COVID-19 by attending in-person appointments with Lifetime Counseling and that such exposure or infection may result in personal injury%2c illness%2c permanent disability%2c and death.%3cspan%3e%26nbsp%3b %3c/span%3eI understand that the risk of becoming exposed to or infected by COVID-19 at Lifetime Counseling may result from the actions%2c omissions%2c or negligence of myself and others%2c including%2c but not limited to Lifetime Counseling%2c their employees%2c volunteers%2c and other participants and their families.%3cspan%3e%26nbsp%3b %3c/span%3e%3c/p%3e %3cp style%3d%22text-align%3a justify%3b%22%3eI voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself and/or my child%28ren%29 %28including%2c but not limited to%2c personal injury%2c disability%2c and death%29%2c illness%2c damage%2c loss%2c claim%2c liability%2c or expense%2c of any kind%2c that I or my child%28ren%29 may experience or incur in connection with my attendance or my child%28ren%29’s attendance at in-person appointments with Lifetime Counseling.%3cspan%3e%26nbsp%3b %3c/span%3eOn my behalf and/or on behalf of my child%28ren%29%2c I hereby release%2c covenant not to sue%2c discharge%2c and hold harmless Lifetime Counseling%2c its employees%2c agents%2c and representatives of and from the claims%2c including all liabilities%2c claims%2c actions%2c damages%2c costs or expenses of any kind arising out of or relating thereto.%3cspan%3e%26nbsp%3b %3c/span%3eI understand and agree that this release includes any claims based on the actions%2c omissions%2c or negligence of Lifetime Counseling%2c its employees%2c agents%2c and representatives%2c whether a COVID-19 infection occurs before%2c during%2c or after participation in any in-person appointments with Lifetime Counseling.%3cspan%3e%26nbsp%3b %3c/span%3e%3c/p%3e %3cp style%3d%22text-align%3a justify%3b%22%3e%26nbsp%3b%3c/p%3e %3cp%3e%26nbsp%3b%3c/p%3e %3cp%3e_____________________________%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e%3c/p%3e %3cp%3eName of Client%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e%3c/p%3e %3cp%3e%26nbsp%3b%3c/p%3e %3cp%3e_____________________________%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3e_____________________________%3c/p%3e %3cp%3eSignature of client/parent%3cspan%3e%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b%26nbsp%3b %3c/span%3eDate%3c/p%3e
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Electronic Signature of Client or Legal Guardian:
Date:
I have read and I agree to the
COVID-19
Financial Policies
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Electronic Signature of Client or Legal Guardian:
Date:
I have read and I agree to the
Financial Policies
Telehealth
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I have read and I agree to the
Telehealth
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Intake
1. How did you hear about us?
2. What type of therapy are you seeking?
Individual
Couples
Family
Hybrid
3. What brings you in?
4. What would your partner say?
5. Length of these relationship:
6. Can you tell me a little bit about yourself and your family/culture/upbringing?
7. Can you tell me a little bit about what intimate relationships look like for you?
8. Do you have any dependents?
9. Therapy before:
10. Psychiatry before:
11. Medications (type & dosage frequency):
12. Alcohol and Drug Use (type & dosage frequency):
Select
0 - 4 drinks a week
5 - 8 drinks a week
9 - 15 drinks a week
15+ drinks a week
Describe use:
13. Marijuana/Cannabis products:
Yes
No
Select
0 - 4 times a week
5 - 8 times a week
9 - 15 times a week
15+ times a week
Do you have a medical marijuana card?
Yes
No
Describe use:
14. Recreational drugs:
Yes
No
Describe use:
15. Suicidality:
Ideation:
Yes
No
Describe, including whether ideation has occurred in the last 2 weeks:
Planning:
Yes
No
Describe, including whether planning has occurred in the last 2 weeks:
Attempts:
Yes
No
Describe including year(s) of occurrence and outcome:
Means:
Yes
No
16. Self Harming Behaviours:
Yes
No
Describe, including most recent incident:
17. Violence Towards Others:
Yes
No
Describe, including most recent incident:
18. Physical/Emotional/Sexual abuse in the past:
Yes
No
Describe:
19. Experience of life being threatened by person, accident, or natural disaster:
Yes
No
20. Hospitalizations for Psychiatric Reasons:
Yes
No
Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:
21. Actions taken concerning above risks:
22. Religious Affiliation/Denomination:
23. Occupation:
24. Preferred Location:
25. School: (grade/year, graduation date & current GPA):
26. City Year Employee: (site name, site grade level, & program manager):
27. Availability:
28. Clinician assigned:
29. Initial Appointment:
30. Client Informed of Fee:
Insurance and/or Sliding scale amount:
31. Client Informed of 2 business day cancellation policy:
Yes
No
32. Who did the intake:
Intake
1. Occupation:
Youth worker:
No describe
Yes describe
2. If City Year Employee: (site name, site grade level, & program manager):
3. How did you hear about us?
4. What type of therapy are you seeking?
Individual
Couples
Family
Hybrid
Group
5. What brings you in?
6. Client stated strengths
7. Can you tell me a little bit about yourself and your family/culture/upbringing?
8. Tell me a little bit about your community & social supports
9. Do you have any dependents?
10. Therapy before:
11. Psychiatry before:
12. Medications (type & dosage frequency):
13. Alcohol and Drug Use (type & dosage frequency):
Select
0 - 4 drinks a week
5 - 8 drinks a week
9 - 15 drinks a week
15+ drinks a week
Describe use:
14. Marijuana/Cannabis products:
Yes
No
Select
0 - 4 times a week
5 - 8 times a week
9 - 15 times a week
15+ times a week
Do you have a medical marijuana card?
Yes
No
Describe use:
15. Recreational drugs:
Yes
No
Describe use:
16. Suicidality:
Ideation:
Yes
No
Describe, including whether ideation has occurred in the last 2 weeks:
Planning:
Yes
No
Describe, including whether planning has occurred in the last 2 weeks:
Attempts:
Yes
No
Describe including year(s) of occurrence and outcome:
Means:
Yes
No
Access to any weapons, if so type:
17. Self Harming Behaviours:
Yes
No
Describe, including most recent incident:
18. Violence Towards Others:
Yes
No
Describe, including most recent incident:
19. Physical/Emotional/Sexual abuse in the past:
Yes
No
Describe:
20. Experience of life being threatened by:
Person
Accident
Natural Disaster
21. Hospitalizations for Psychiatric Reasons:
Yes
No
Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:
22. Actions taken concerning above risks:
23. Religious Affiliation/Denomination:
24. Preferred Location:
25. School: (grade/year, graduation date & current GPA):
26. Availability:
27.Insurance and/or Sliding scale amount:
Everything below is for Office Staff Only to Complete
28. Clinician assigned:
29. Initial Appointment:
30. Client Informed of Fee:
31. Client Informed of 2 business day cancellation policy:
Yes
No
32. Who did the intake:
32. Youth worker:
Yes
No
33. Describe if not occupation
(under occupation)
Intake
1. How did you hear about us?
2. What type of therapy are you seeking?
Individual
Couples
Family
Hybrid
3. What brings you in?
4. Suicidality:
Ideation:
Yes
No
Describe, including whether ideation has occurred in the last 2 weeks:
Planning:
Yes
No
Describe, including whether planning has occurred in the last 2 weeks:
Attempts:
Yes
No
Describe including year(s) of occurrence and outcome:
Means:
Yes
No
5. Violence Towards Others:
Yes
No
Describe, including most recent incident:
6. Hospitalizations for Psychiatric Reasons:
Yes
No
Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:
7. Client Informed of Fee:
Insurance and/or Sliding scale amount:
8.Client Notes
a:
b: