Life Counseling Services

Thank you for your interest in Life Counseling Services. Please fill out the information below and an intake worker will call you within 48 hours to offer you an appointment time. If you already have a therapist and need to submit your information for billing please list the therapist's name in the additional questions area.

Information Request Form

Last Name
First Name
Home Address
Home Phone #
Work or Cell Phone #
Employer
Email
Date of Birth

Social Security #
Type of Insurance (ie. Personal Choice)
Insurance ID #
Who is the subscriber on your insurance policy?
Subscriber's date of birth
"Provider" phone number on back of insurance card
Emergency Contact
Emergency Contact Phone #
Which Location
Preferred Appointment Time	Day Evening
Faith (optional)
Briefly explain the issues you would like to discuss.
Any questions you need us to answer?

Your therapist will be chosen based on the issues you have identified. Also the closest office location will be chosen by the address indicated. All of our therapists are licensed professionals. If you have any questions for your therapist you may ask them when the counselor calls to offer you an appointment.

Once an appointment is scheduled for you we have a cancellation policy which requires a 48 hours notice. If you are unable to give us 48 hours notice there is a late cancellation fee unless the cancellation is due to illness or emergency.