Lifestyle Management Counseling Center

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Address

Reason for care

What is the reason for seeking care? Please be detailed.

Limited to 600 characters

Administrative

Referral Source

Indicate who referred you to our services

Billing & Payment

Payment Method

What method of payment will you be using?

Insurance Details (if not applicable write "none")

Policy # / Member ID / EAP Authorization #

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred Appointment Time

Morning Afternoon Evening Weekend

Preferred clinician

Select a clinician from the list

Preferred Modality

Where do you prefer your appointments to ccurr?

Is there anything else that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.