Lifetime Counseling
138 Park Avenue Suite 214
Winder GA 30680-2365
678-425-9007
PRIMARY CLIENT INFORMATION
First Name
*
Middle Name
Last Name
*
Name :
Nick name :
Gender :
Select
Male
Female
Other
Date of birth :
*
Address :
City :
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
Zip :
Country :
Select
US
CA
BB
SG
County :
Email :
Home Phone :
Cell :
Click here to enter Additional Client Info
Calling Restrictions :
Referred By :
Employer :
Phone :
Address :
Emergency Contact :
Relationship :
Phone # :
Click here to enter Partner Information
PARTNER INFO
Name :
Date Of Birth :
Age :
Employer :
Phone :
Street :
City :
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
Zip :
Country :
Select
US
CA
BB
SG
PRIMARY INSURED
Insurance
Self Pay
EAP
Third Party
First Name
Middle Name
Last Name
Name :
Nick Name :
Gender :
Select
Male
Female
Other
Date Of Birth :
Address :
City :
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
Zip :
Country :
Select
US
CA
BB
SG
Occupation :
May we call at work?
Yes
No
Work Hours :
Copay :
Primary Insurance Information
CarrierName :
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
Group Health Insurance
Humana
Magellan Behavioral Health
Multiplan
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.
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
Zip :
Member/Subscriber # :
Country :
Select
US
CA
BB
SG
Phone :
Relationship :
Select
self
Spouse
child
other
Click here if you have Secondary Information
SECONDARY INSURED ("If Applicable")
First Name
Middle Name
Last Name
Name :
Nick Name :
Gender :
Select
Male
Female
Other
Date Of Birth :
Address :
City :
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
Zip :
Country :
Select
US
CA
BB
SG
Occupation :
May we call at work?
Yes
No
Work Hours :
Copay :
Secondary Insurance Information
CarrierName :
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
Group Health Insurance
Humana
Magellan Behavioral Health
Multiplan
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.
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
Zip :
Member/Subscriber # :
Country :
Select
US
CA
BB
SG
Phone :
Relationship :
Select
self
Spouse
child
other
Click here to enter Terms Information
Terms and Policy
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 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:
12. Alcohol and Drug Use:
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:
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. Hospitalizations for Psychiatric Reasons:
Yes
No
Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:
20. Occupation:
21. Preferred Location:
22. Availability:
23. Clinician assigned:
24. Initial Appointment:
25. Client Informed of Fee:
Sliding scale amount:
26. Client Informed of 2 business day cancellation policy:
Yes
No
27. Who did the intake: