Client Portal - Life Tree Counseling Center, Inc.

Appointment Request

Please complete the Appointment Request, in full. After you submit, you will be sent an email to create a username and password which will give access to your dashboard, self scheduling and communication with your provider. Thank you!

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Please select a Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

Go to the CALENDAR icon to self schedule your appointment OR call your therapist directly.

Insurance:

Insurance Company Name:

Member #:

Group #:

Coinsurance (%):

Copay:

EAP Information:

Employee Assistance Program Name:

EAP Authorization Code:

Phone Number:

Submit

Cancel

Personal Information

Contact Information

Phone

Address

Please Select a Provider:

Please explain the reason you are seeking help at this time:

Insurance