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Our Intake Specialist will follow up within 24-48 business hours.
First Name*
Last Name*
Name of Person Submitting this Form
Phone*
Phone Type
Work
Home
Mobile
Email*
Preferred Contact Method
Text
Email
Phone
Date of Birth
Method*
In-Person Only
Virtual Only
Hybrid Option
Preferred Provider
Please describe why you are seeking counseling:*
Availability: Days of the Week*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Availability: Time of Day*
Early Mornings (7a-9a)
Mornings (9a-12p)
Afternoons (12p-3p)
Late Afternoons (3p-5p)
Evenings (5p-8p)
Insurance Carrier*
Aetna
ASR
Blue Cross Blue Shield PPO
Blue Care Network HMO
Cigna
Mclaren Commercial
Medicare Part B
Medicare Plus Blue
Medicaid: Blue Cross Complete
Medicaid: Mclaren
Medicaid: Meridian
Medicaid: Molina
Medicaid: Priority Health
Medicaid: United Health Care
Priority Health Commercial
Priority Health Narrow Network
Self Pay
United Healthcare Commercial
Other - note below
Insurance Carrier - Other
Insurance ID
Referral Resource
Current Client
Psychology Today
Discharge Planner at Hospital or Facility
School Counselor/Counseling Center
PCP Referral
Social Media
Friends/Family
Insurance Company Directory
Counselor in the Community
Google Search
Other
*At Life Support LLC, we understand that your privacy is important. That's why we offer an opt-in policy for text & email communication with our office. When you inquire about our services, you have the option to provide your mobile number and email
Yes, please contact me by my preferred method above
Please do not use text or email
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