Online Intake Form

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

 

If you would prefer to discuss this information directly with a member of our administrative staff, call our office at 512-469-9447 between 9:00 and 1:00 any weekday.

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.

© 2015 by Stephen Pieringer of New Life Institute