Integrative Psychotherapy Services
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Request Information
In order to best determine the appropriate services for you at Life Changes, please take the time to complete the following questions (5 minutes). Once submitted to our website, a representative will be in-touch with you within one business day.
 

First name:   Middle Initial:

Last Name:  

Date of Birth:

E-mail:

Address:

Address 2:

City: State/Province: Zip/Postal Code:

Home Phone: - - Work Phone: - -

Mobile Phone: - -

How were you referred to this practice?
Internet Search
Doctor
Psychologist

What clinician, if any, are you hoping to see?

Has this individual or any other immediate family member ever been seen at our practice?

Yes       No

If yes, who (Previous patient's name and clinician seen)

Marital Status:

Have you used any mental health insurance
benefits this calendar year? Yes       No

How many visits with a mental health clinician have you had this year?

Are you currently seeing any other mental health provider? Yes       No

If yes, please provide the name(s) and telephone number of those clinicians:

Have you ever been hospitalized for psychiatric reasons? Yes       No

If yes, when was the last hospitalization?

Do you plan to use a health plan to pay for our services? Yes       No

If so, what type of health plan do you have?

Name of subscriber on insurance policy?

What is your Plan Identification Number?

What is your Plan Suffix number?

Health plan telephone number for
mental health benefits? - -

Subscriber's Social Security Number - -

Please briefly describe the nature of the problem you are seeking services for.

What type of services are you seeking? Check all that apply.

Individual Psychotherapy

Family Therapy

Group Therapy

Neuropsychological Evaluation

Psychological Evaluation

Consultation

Intelligence / Achievement Testing

Developmental Evaluation

Other, please specify:

Do we have permission to leave a general message
on your answering machine? Yes       No

When would you be able to come for services on a regular basis?

(GIVE SPECIFIC DAYS & TIMES)