New Patient Intake Form

Complete this form before your first appointment to help us prepare for your visit. This should take about 10 minutes.

Before you begin: This form collects basic information to help our clinical team prepare for your intake appointment. All information is kept strictly confidential in accordance with HIPAA. If you need assistance completing this form, please call us at (602) 319-5155.

1. Personal

2. Insurance

3. Health History

4. Emergency Contact

5. Consent

First Name *

Last Name *

Date of Birth *

Gender Identity

Phone Number *

Email Address

Home Address *

City

Zip Code

Preferred Language

Race / Ethnicity (optional)

How did you hear about us?

Insurance Type *

Member ID / AHCCCS ID

Group Number

Insurance Phone

Primary Insurance Holder (if not yourself)

Relationship to Insurance Holder

Not sure about your coverage? Leave it blank and our intake team will verify your benefits before your appointment at no cost.

What brings you to Life Changing Wellness today? *

Have you received behavioral health services before?

Current Medications (psychiatric or otherwise)

Known Allergies

Do you have any current thoughts of harming yourself or others?

If you are in crisis right now, please call 988 or (602) 222-9444 (Maricopa County Crisis Line) or go to your nearest emergency room. Do not wait for an appointment.

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

May we contact them about your care?

Legal Guardian (if patient is a minor or has a legal guardian)

Guardian Name

Guardian Phone

Consent to Treatment

By submitting this form, I voluntarily consent to receive behavioral health services from Life Changing Wellness and Treatment Center. I understand that I may withdraw consent at any time.

HIPAA Acknowledgment

I acknowledge that I have been informed of my rights under HIPAA and have been given the opportunity to review the Notice of Privacy Practices. I understand how my health information may be used and disclosed.

Patient Rights

I acknowledge receipt of the Patient Rights and Responsibilities and agree to abide by the responsibilities outlined therein.

I have read and agree to the consent to treatment, HIPAA acknowledgment, and patient rights and responsibilities. *

Electronic Signature (type your full legal name) *

Today's Date

✓ Intake form submitted! Thank you. Our intake team will review your information and contact you within 24–48 hours to confirm your appointment. If you have not heard from us, please call (602) 319-5155.