LIFEBACK INTAKE FORM • GO Church

Thank you for reaching out to take the first step toward recovery. In order for us to counsel you to the best of our ability and to schedule an appointment, it is necessary to collect some information. Please take a moment to complete the intake form to begin the intake process. Once you submit the form, your information will be reviewed and we will contact you to schedule your next step.

Each Counseling Session is $65.00

NOTICE

If this is an emergency situation concerning your safety, mental health, or the safety of another individual,

please STOP NOW and call 988

First Name *

Last Name *

Mobile Number *

Email Address *

Locations *

South Metro ATL

Montgomery County

Online

Westside

Date of Birth *

Gender *

Address *

City *

State *

Zip Code *

Please tell us what you are experiencing and/or what has happened to cause you to seek counseling *

Are you Currently serving in a ministry at GO Church *

YES

If YES please detail *

MEDICATIONS (Name and purpose of use) *

Have you had Psychotherapy or Counseling before? If yes, describe outcome *

Late Cancellation and No-Show Policy

You will receive a text, email, or voice reminder of your scheduled appointment. These reminders are 24-48 hours prior to your scheduled appointment time. It is imperative that you confirm or request to cancel your appointment within 24 hours of your appointment time. Failure to do so will result in your account being charged a late cancellation fee, which is your session/service fee full amount. An exception to this would be an emergency or sickness only. Providing timely notice allows us to offer your canceled appointment to someone else.

Before submitting this form please be sure to read the 'Statement of Understanding" below by clicking the green link.

By submitting this form you acknowledge you have read and agree to the Statement of Understanding