Lotus Counseling Services, LLC

Lotus Counseling Services, LLC Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

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Reason for care

What is the reason for seeking therapy?

Depression Anxiety Trauma Relationship Issues Grief Self-Esteem/Body Image Attentional difficulties Obsessive-Compulsive Symptoms Substance Use Legal Reasons Provider Referral

Administrative

Referral source

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Driver's license upload

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Billing & Payment

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Insurance details

Who is the main subscriber? [name, date of birth, address, phone number]

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Insurance card upload

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Client Preferences

Preferred appointment times

What days/times are you available for scheduled appointments?

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Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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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.