HeartLife Professional Soul Care

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

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Please provide any info we may need to best connect you to a counselor. If appt is for multiple people, please note how many.

Limited to 600 characters

What services are you requesting?

Individual Counseling Couples Counseling Child/Adolescent Counseling Psychoeducational Testing

FOR MINORS ONLY: Custody/Family Information:

We will ask you to provide documentation of custody if divorced parents do not both agree to participate in therapy/counseling or if one has decision-making authority.

Parents are married Parents are divorced, Joint Custody Parents are divorced, One Parent has decision-making authority Parents Never Married

Administrative

How did you hear about HeartLife?

Enter how you were referred to our services

Preferred method of contact?

Phone Email Either

What days/times are you available?

Billing & Payment

Please read:

I understand HeartLife is private pay does not have relationship with insurance or Managed Care Companies. Please visit our website to learn more about payment options. www.heartlifesoulcare.org/pricing

Client Preferences

Preferred clinician

Select a clinician from the list

Preferred modality

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.