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