LifeBack - Get Yours

Patient Forms

Intake Forms & Helpful Information

GENERAL FORMS

Intake Documents
Overall Health Wellness Questionnaire
Acknowledgement of New Patient Information
Consent to Treatment
Financial Policy
HIPAA Notice of Privacy Practices/Receipt and Acknowledgment
Medical Records Request
Patient Rights

NEW JERSEY OFFICE

NJ Mental Health Patient Rights and Grievances
NJ Release of Information

PENNSYLVANIA OFFICE

PA Mental Health Bill of Rights
PA Mental Health Program - Release of Information
PA Substance Use Program Release of Info - Insurance Consent
PA Substance Use Program Release of Information - Lab Screen
PA Substance Use Program Release of Information

For more information about LifeBack

(609) 482-3701

About Us
Contact Us
Crisis Information

LifeBack is state licensed and accredited Mental Health and Psychiatric agency. Our dedicated team provides services to children, adolescents, and adults; utilizing a wide range of evidence based practices.

New Jersey

Pennsylvania