Site Policies

Please do not come on campus without an appointment

COVID-19 Informed Consent: Read here

Grace Fellowship Church of Buckeye reserves the right to limit access to the church campus regardless of LLCS client status

Be advised there is an school on campus and visitors may be approached by church or school personnel as a security precaution. Inform anyone asking of your appointment with LLCS.
Please note church and school staff are not LLCS affiliated. Show discretion in sharing personal information with anyone other than an LLCS clinician, as they are not bound by confidentiality law
Please enter the C BUILDING entrance and be seated
If your clinician is unable to meet you immediately, you may alert them via text of your arrival
If you are 10 minutes into your session without being acknowledge by your clinician, it is possible there is an emergency with another client. They will inform you if rescheduling is required.
Please do not come on campus if under the influence of alcohol or a substance
Please be courteous to anyone you meet while on site
This is a smoke free campus
There is a restroom in each of the C building meeting room and in the main church breezeway

Please DO NOT BRING any of the following items onto the GFCB Campus

Firearms or any objects that may be mistaken as weapons (weapons free zone)
Alcohol, Tobacco products or any other illicit drugs
Animals, unless officially certified service animals (certification may be requested)

Please BRING the following items to the first session:

Completed Client Demographic Form (Complete as best as possible)

Complete the Client Intake (as best as possible)
Insurance card (if applicable)
Copies of legal custodial or guardianship paperwork (for minor clients)

Please contact LLCS as soon as possible should you have any questions. Thank you.

Types of Intakes

One hour

Explanation of informed Consent (state mandated)
Roughly 15 min for gathering personal History
Possible completion of intake assessment
Intake completed in 2 sessions and less expensive

Two hour

Explanation of Informed Consent (state mandated)
Roughly 75 min for gathering personal History
Completion of intake assessment
Completion of Treatment Plan
Intake completed in 1 session but more expensive

Additional information

If you desire to complete your intake in 1 hour, please only register and pay for 1 hour
All fees will be applied as a credit to any Insurance Deductibles, Copays, or Coinsurance, or against any insurance non-covered services or missed session fees.
This fee is Refundable/Transferable if a request for cancellation/rescheduling is received and confirmed with 24 hours advance notice

Directions

Directions: Light of Life Counseling Services is located on the campus of Grace Fellowship Church of Buckeye (GFCB) which is SOUTH OF SOUTHERN AVE on Miller Rd. GFCB is on the west side of Miller Rd.

***If GPS places the church north of the I-10, this is incorrect!

***Best place to park is in the south parking lot

Your Information

Information about the person filling out the form either on behalf of the patient or for themselves

Name(Required)

First Last

Is the patient a minor under 17 years old?(Required)

Relationship to patient (minor)(Required)

Relationship to patient (adult)(Required)

Date of Birth(Required)

Scheduling Service for Minors

You indicated that the patient is a minor. Please attest to the following statements as part of your scheduling request.

Decision Making Rights(Required)

I attest that I hold “sole” or “full” court ordered decision making rights for the minor I am seeking to enroll in therapy services. I also agree to provide a copy of the court order prior to the intake session.

Informed All Adults With Decision Making Rights(Required)

I attest, I have informed all other adults with decision making rights over the minor of my intention to enroll him/her in therapy services through LLCS.

Court Custodial Order Required(Required)

I understand LLCS may suspend the intake and future services without prior receipt of a copy of the court custodial order and signed consents by all decision-making adults to include forfeiture of deposits

Legal Guardians Must Be Present(Required)

I understand legal guardians must be present for the full intake session

Scheduling Service for Another Adult or a Minor 17+

LLCS recognizes that most efforts by an adult to schedule services for another adult are to assist someone with a busy schedule to register for services. However, please know therapy is ineffective if individuals are pressured to attend

Therapist Will Confirm Patient's Desire For Therapy(Required)

I understand the LLCS therapist must confirm with the patient their desire for therapy services

LLCS Cannot Confirm If Patient Declines Service(Required)

I understand LLCS cannot confirm if an identified patient declines service

Scheduling Services For Myself May Be Beneficial(Required)

I understand scheduling services for myself may be beneficial even if the other individual declines

Patient Information

You indicated the patient is not yourself. If the patient is a minor, enter your information. If the patient is another adult, enter their information.

Patient Name

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Information

Name(Required)

First Last

Relationship to patient(Required)

Role/Title(Required)

Phone(Required)

Your Therapist and Service Request

Service Type(Required)

In Person or Telehealth?(Required)

Wait Time Agreement(Required)

I understand that this therapist is presently estimating a {{wait time}} week wait time for service intake. This is an estimate and services may begin earlier or later depending on client’s scheduling availability.

Patient Availability

1st most desired service time day(Required)

Choose a time(Required)

2nd most desired service time day(Required)

Choose a time(Required)

3rd most desired service time day(Required)

Choose a time(Required)

Service Continuation Agreement(Required)

I understand completing an intake is not a guarantee of LLCS service continuation for reasons listed:

The intake reveals a patient need for specialized services beyond LLCS therapist's expertise
The intake reveals a patient need for a higher level of care than outpatient treatment
The patient discloses they cannot regularly attend their previously identified available time
The patient breaks LLCS Service Policies

LLCS Policies Agreement(Required)

I have read and agree with LLCS Policies

Click here to open LLCS Policies in a new tab

Waitlist Agreement(Required)

I understand that LLCS's waitlists are non-binding, and I may decline services at any time. However, when contacted, I must respond within 2-3 days, or I risk losing my place on the waitlist.

Patient Financial Information

LLCS wil be billing the following for payment of patient services(Required)

Household Annual Income(Required)

Number of Dependents(Required)

Insurance Company Name(Required)

Insurance Company Policy ID#(Required)

Active Date

EAP Benefit?(Required)

EAP Company Name(Required)

EAP Company Phone Number(Required)

Is the patient the Primary Insured?(Required)

Primary Insured Name(Required)

First Middle Last

Primary Insured Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insured Phone(Required)

Is the Patient the Guarantor of Services?(Required)

Guarantor Name(Required)

First Middle Last

Guarantor Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Guarantor Phone(Required)

Intake Scheduling Deposit Information

When contacted to schedule an intake session, LLCS requires a $75 deposit as insurance does not pay for missed sessions. The deposit must be paid prior to the intake to confirm its scheduling.

Agree to 24 hour notice for intent to cancel or reschedule(Required)

I agree to directly confirm with my LLCS clinician via phone, text, or email of my intent to cancel or reschedule the intake with 24 hours' notice.

Agree to pay $75 deposit(Required)

I agree to pay a $75 intake scheduling deposit (regardless of using insurance) and that I may forfeit this deposit if I do not give my therapist 24 hours' notice to cancel or reschedule the session.

Agree to second $95 deposit if first intake session is missed(Required)

I agree that LLCS reserves the right to charge a second $95 deposit to schedule another intake session if the first is missed without 24 hours' notice of cancelation to session rescheduling.

I agree to patient payment responsibility(Required)

I agree that LLCS may apply the intake against any patient payment responsibility (i.e. copays, co-insurances, or deductibles) and that it will be returned if there is no confirmed payer responsibility.

Intake Session and Portal Access Creation

Once registration is submitted, the patient will be contacted with a tentative intake date. At this time the patient will receive the portal account access and must complete the following actions.

I have access to email and the Internet(Required)

Intake Confirmation Through the LLCS-InSync Portal (preferred)(Required)

I understand that to confirm my intake session, I will need to sign onto the LLCS-InSync Portal to complete the following actions:

I must electronically complete the LLCS Information and Consent Packet - Everyone
The LLCS Informed Consent For In-Person Services During A Public Health Emergency (PHE) - Unnecessary for Telehealth
Patient Adult History or Child History which applies
Upload copies of any required custodial orders
Pay the Intake Deposit online

Intake Confirmation when LLCS-InSync Portal is not available(Required)

I agree that if I cannot complete the consent forms online or pay the deposit, I will:

Bring copies of required custodial orders
I will call my therapist or LLCS office to pay the deposit over the phone
Print the forms and bring the completed forms to the intake session:

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New Intake Form — TESTING

Intake 1

Types of Intakes

One hour

Two hour

Additional information

Directions

Your Information

Scheduling Service for Minors

Scheduling Service for Another Adult or a Minor 17+

Patient Information

Emergency Contact Information

Your Therapist and Service Request

Patient Availability

Patient Financial Information

Intake Scheduling Deposit Information

Intake Session and Portal Access Creation

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