Live Well Counseling Services, LLC

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

Sex at birth

For insurance verification

Address [Full address, including city and state]

Please list the full street address that is on file with the insurance company. [This should not be a PO Box]

Administrative

Referral source

Enter how you were referred to our services

Are you requesting a specific practitioner?

What's the best way for us to contact the client for sessions?

Phone call Text Email

If you are not the client requesting services, what is your relationship to the client as well as a phone number and/or email address incase we need to follow up with you.

Limited to 600 characters

Billing & Payment

Payment method

How do you plan to pay?

Insurance card upload

Upload a photo of your insurance card

Who is the policy holder on the insurance plan?

Please list their first and last name [ex - Mary Smith]

What is the date of birth policy holders (the person who carries the insurance)?

Please list like [00/00/0000]

What is the relationship of the policy holder to the client

Self Parent Child Spouse Other

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.