Life Center Columbus Intake Form

Life Center Columbus - INTAKE FORM

Enter your information below
Client Information
Client Name

First NameMiddle InitialLast Name
Client Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Gender
Client Age
Client Grade
Client School
Parent/Guardian Information
Parent/Guardian - First/Last Name

First NameLast Name
Parent/Guardian Phone
Format: (000) 000-0000.
Parent/Guardian E-mail Address
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transportation Needs
Will your child need transortation
Emergency Contact Information
Emergency Contact

First NameLast Name
Relationship to Client
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Authorized Pick-Up List
Who is allowed to pick the client up besides the parent?

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who is allowed to pick the client up besides the parent?

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Counseling & Program Services

Please check all that apply. This section is mandatory.
Counseling. Services: Please check the appropriate boxes to indicate your approval:
Medical & Health Information
Does your child have allergies?
If yes, please describe the allergy
Medical Conditions(e.g., asthma, diabetes, ADHD)
If yes, please describe the medical condition.
Does your child currently take prescribed medications that we should be aware of for emergency purposes only?
If yes, please describe the medications.
Insurance Information

Please complete the following information for counseling and emergency care.
Health Insurance Provider
CareSource, United Healthcare, Molina, etc
Member/Subscriber ID Number
Group Number (if applicable)
Note: Please bring your child's physical insurance card to the first appointment so a copy can be added to their file.
Permissions & Approvals

Please select all that apply. This section is mandatory.
Please check all that apply. This section is mandatory.

I authorize The Life Center Columbus to verify my child’s insurance and Medicaid eligibility and to submit claims for covered behavioral health, assessment, treatment, and related services provided to my child. I authorize The Life Center Columbus to provide the insurance plan, Medicaid program, managed care organization, or other authorized payer with information reasonably necessary to process, review, and pay claims for services provided.I authorize payment of applicable insurance or Medicaid benefits directly to The Life Center Columbus for covered services provided to my child.
Parent Communication Consent
IParents Name* parent/guardian name), give permission for The Life Center Columbus to contact me once every three months regarding my child’s progress, participation, and any important updates related to the program. I understand that these communications may occur by phone, email, or text message.
Welcome to LIFE CENTER COLUMBUS (LCC)

Before your child can begin participating in our program, it is important to complete the intake and assessment process. This process allows us to understand your child’s unique needs so we can provide the most effective support and services.

Please provide your contact information above. A member of our team will contact you to schedule your intake application and initial assessment.

Thank you for choosing LIFE CENTER COLUMBUS. We look forward to supporting your child’s growth, development, and success through our program.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Card

Cancelof
After you submit this form, a member of The Life Center Columbus team will contact you to help set up your child and family in our secure communication system.

This system will be used for:
- Appointment scheduling and reminders
- Secure communication with our staff
- Completing or receiving required forms and documents
- HIPAA-compliant communication regarding your child’s services
- Updates and next steps related to care
Please watch for a phone call, text message, or email from our team after submitting this form.
Parent/Guardian Signature
Should be Empty:

Life Center Columbus - INTAKE FORM

Client Information

Parent/Guardian Information

Transportation Needs

Emergency Contact Information

Authorized Pick-Up List

Counseling & Program Services

Medical & Health Information

Insurance Information

Permissions & Approvals

Parent Communication Consent