New Clients

Welcome to LifeWorks Counseling!


Thank you for filling out this form for new patients. It will help us serve you.

Basic Information


Contact Info

  • If the above patient is a minor complete the following:


Insurance Info


Referral Source


Emergency Contact Information


History Information


Previous Treatment


Developmental History


Medical History


Family History


Educational History


Occupational History


Marital History


Substance Abuse History


Additional Information