Life Focus Center

View Our Annual Financial Reports

Home
About
Services
Groups
Blog
Events
- Love and Respect Marriage Group
Contact
LFC 6K

Complete Intake Form

Intake Form

Life Focus Center

Initial Intake Screening

Completing this form allows us to better understand your needs so we can connect you with the counselor who is most qualified to walk with you through this season.

Contact Us

Full Name

Age

Email

Phone

Preferred Method of Contact:

Call

Text

Email

Name of Preferred Counselor

1. What brings you to counseling at this time?

2. Have you experienced any of the following? (Check all that apply)

Ongoing Anxiety or Panic

Persistent sadness or hopelessness

Trauma (past or recent)

Grief or Loss

Abuse (emotional, physical, sexual, spiritual)

Relationship or family conflict

Parenting concerns

Anger that feels out of control

Faith or spiritual struggles

Other

If other was checked, please share what feels safe to share:

3. Safety & Severity Check (past 6 months)

Thoughts of harming yourself

Thoughts of harming someone else

Self-harm behaviors

Suicidal thoughts (even if passive or fleeting)

A suicide attempt

Hospitalization for mental health reasons

Feeling emotionally overwhelmed most days

Feeling unable to function in daily responsibilities

If any are checked, please share what feels safe to share:

Free Text

4. Current Stability & Support

Do you feel safe right now?

Yes

Unsure

No

Do you have supportive people in your life?

Yes

Some

Very limited

Seeing another counselor?

Yes

No

Taking psychiatric medication?

Yes

No

5. Anything else you feel is important for us to know right now?

Thank you for completing the LFC initial intake screening.

One of our counselors will get back to you within 24 hours.

Oops, there was an error sending your message.

Please try again.

Want more information?

© 2026

Life Focus Center

Powered by CL Design Studios

Home
Services
Home
Contact
Home
Events

Moorestown Location

301 N. Church Street, Suite 101

Moorestown, NJ 08057

___________________________

Galloway NJ Location

733 E. Lily Lake Rd. Galloway, NJ 08205

Latest News

Insurance Policy:

LFC does not accept insurance, however you can submit forms to your insurance company for possible reimbursement.

Share by: