Mental Health Forms & Resources

LiveWell Counseling

We encourage you to download the appropriate forms below, complete it on your computer, and then print and return it to us either in person or via U.S. Mail. You may also return it via email.

• Appointment Information
• Summary List
• Primary Care Physician Information
• Medicare Questionnaire
• Insurance Provider Information
• HIPAA Acknowledgment Form
• Health Nutrition and Pain Assessment (Adult)
• Health Nutrition and Pain (Child-Adolescent)
• Financial and Service Agreement
• Financial and Service Agreement for Minors
• Child Adolescent Behavioral Checklist
• Authorization to Contact or Leave Messages
• Authorization for Outpatient Treatment Consent Form
• Financial Assistance Policy Summary
• Financial Assistance Policy Summary - Spanish
• Complete Financial Assistance Policy
• Financial Assistance Application

To complete and save these forms online, you will need to have the latest version of Adobe Reader® installed. Click here to download this free software directly from Adobe’s website.