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Intake Form

If you’ve come this far you are hurting and need HELP!  We take seriously your counseling needs.  If you will complete the form below we will be back to you between 9:00 am and 1:00 pm on the next business day, if not sooner.

If this is an emergency call: 911 OR 472-HELP OR go to the nearest emergency room.

Some Insurance Accepted

Limited Need-Based Fee Schedule

Your Name (required)

Patient's Name (if different)

Your Email (required)

Phone Where You May Be Reached

Issues for Counseling (Depression, Anger, Relationships, Marriage, etc.

How did you hear about New Life?

Insurance Company

Monthly Income if no Insurance

To reduce costs, will you see an intern?

Prefer a Male or Female counselor

CONFIDENTIALITY NOTICE: This document, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential information and privileged information. Any unauthorized retention, review, printing, copying, disclosure or distribution is prohibited. New Life Institute will keep confidential all information transmitted in this document except as is needed to connect a counselor with the person completing this document.