LifeBack - Get Yours

Patient Forms

Email Our Intake Department

Intake Forms & Helpful Information

GENERAL FORMS

Medical Records Request
Intake B. Patient Intake Form
Intake C. Intake Packet
Intake D. Person Permitted to Schedule Appointments, Have Portal Access, & Handle Medication Management
Intake E. Agreement Regarding Minors

(only to be completed if identified patient is younger than 18 years of age; must be signed by a parent/guardian)

NEW JERSEY OFFICE

NJ Release of Information
Advanced Directive Information
Summer Heat and Sun Risks with Psychotropic Medications

PENNSYLVANIA OFFICE

PA Mental Health Program - Release of Information
Non-Discrimination In Services Policy

For more information about LifeBack

(609) 482-3701

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Crisis Information

LifeBack is state licensed 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