Name
First Name
Last Name
Age
Phone Number
Email
example@example.com
Reasons for Seeking Therapy
Do you have a preference for Day of Week and Time of Day, or would you like a first available appointment?
How frequently do you prefer to meet?
Weekly
Every 2-3 Weeks
Monthly
Every 6-8 Weeks
Quarterly
I prefer to meet:
Telehealth
Our rates are $150/Assessment and $130/55 minute session. Please select your preferred method of payment.
Plan to Utilize Insurance
Private Pay
If you plan to use insurance, what kind of insurance do you have?
If you plan to use insurance, what kind of insurance do you have?
Blue Cross Blue Shield
Lucet
Uprise Health
BHS
Cigna
Private Pay
Do you have any questions before we schedule?
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How did you hear about Lifeline?
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