LIFESUPPORTLLC -

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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: Time of Day *

Early Mornings (7a-9a)

Mornings (9a-12p)

Afternoons (12p-3p)

Late Afternoons (3p-5p)

Evenings (5p-8p)

Insurance Carrier - Other

Insurance ID

Have you ever been discharged from previous provider (Physician, NP, PA?) *

Yes

No

If you are requesting ADD/ADHD medicine have you had formal testing? *

Yes

No

Not interested or prescribed ADD/ADHD medicine

Any of the following addiction treatment medications *

Naltrexone or Vivitrol

Buprenorphine, Suboxone, and Methadone

Disulfiram or Antabuse

Acamprosate or Campral

None of the above

By submitting, you agree to receive text messages at the provided number from Life Support LLC. Message frequency varies, and standard message and data rates may apply.

Yes, please contact me by my preferred method above

Please do not use text or email

You have the right to OPT-OUT receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.

I understand I have the option to OPT-OUT at any time.