×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
×
Show/Hide Border
Table Properties
Delete Table
Row
Insert Row Above
Insert Row Below
Delete Row
Column
Insert Column to the Left
Insert Column to the Right
Delete Column
Cell
Merge Cells Horizontally
Merge Cells Vertically
Split Cell Horizontally
Split Cell Vertically
Delete Cell
Cell Properties
Table Properties
Properties...
Image Map Editor
Properties...
OpenLink
Remove Link
Insert Select
Cut
Copy
Paste
Paste from Word
Paste Plain Text
Paste As Html
Paste Html
Paragraph Style
Font Name
Real font size
Apply CSS Class
Custom Links
Zoom
RadEditor hidden textarea
Secure Site
Lifetime Counseling
138 Park Avenue Suite 214
Winder GA 30680-2365
678-425-9007
PRIMARY CLIENT INFORMATION
Select Legal Gender
Male
Female
*
Select Gender Identity
Agender
Bigender
Cisgender Female
Cisgender Male
Female
Genderqueer
Genderfluid
Gender Non-conforming
Intersex
Male
Non-Binary
Other
Questioning
Transfemale
Transmale
Transgender Female
Transgender Male
Two-Spirit
Choose Not To Disclose
Select State
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
Select Sexual Orientation
Androsexual
Asexual
Bisexual
Demisexual
Gay
Gray-Asexual
Gynesexual
Heterosexual
Homosexual
Lesbian
Other
Pansexual
Polyamorous
Queer
Questioning
Sapiosexual
Choose Not To Disclose
Select
US
CA
BB
SG
BVI
Pronouns
He/Him/His
He/Them
She/Her/Hers
She/Them
They/Them/Theirs
Other
Choose Not To Disclose
Select Location
LCGA-Winder
Nicole Huseman
Select Language
English
Spanish
French
Chinese
American Sign
Select Ethnicity
Hispanic (or Latino/Chicano)
Non-Hispanic (or Latino/Chicano)
Select Programs
Select
Select Race
American Indian or Alaska Native
Asian
Black or African American
Caucasian
Dominican
Italian
MIEN
Multi-Racial
Native Hawaiian or other Pacific Islander
Other
White
Preferred Providers
LCGA-Kathryn Nicole Huseman
LCGA-Tim Neville
Click here to enter Additional Client Info
Click here to enter Partner Information
PARTNER INFO
Second client Registration
Select Legal Gender
Male
Female
Select State
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
Select
US
CA
BB
SG
BVI
PRIMARY INSURED
Insurance
Self Pay
EAP
Third Party
Select Legal Gender
Male
Female
Select
Agender
Bigender
Cisgender Female
Cisgender Male
Female
Genderqueer
Genderfluid
Gender Non-conforming
Intersex
Male
Non-Binary
Other
Questioning
Transgender Female
Transgender Male
Two-Spirit
Select State
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
Select
US
CA
BB
SG
BVI
May we call at work?
Yes
No
Primary Insurance Information
Select Carrier Name
Select
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)
Select State
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
Select
US
CA
BB
SG
BVI
Select Relationship
Child
Self
Spouse
Other
Click here if you have Secondary Information
SECONDARY INSURED ("If Applicable")
Select Legal Gender
Male
Female
Select
Agender
Bigender
Cisgender Female
Cisgender Male
Female
Genderqueer
Genderfluid
Gender Non-conforming
Intersex
Male
Non-Binary
Other
Questioning
Transgender Female
Transgender Male
Two-Spirit
Select State
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
Select
US
CA
BB
SG
BVI
May we call at work?
Yes
No
Secondary Insurance Information
Select Carrier Name
Select
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)
Select State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY