Living Bread Intake Form

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We offer assistance based on a sliding scale. A separate form, including documentation, will be required.

Currently, we can only file BCBS insurance for mental health counseling; however, we can provide receipts for you to file your own insurance.

This form will automatically be submitted to the Intake Coordinator at If you have any questions once this form is submitted, you can email them to us at that address.

Thank you so much for your interest in Living Bread!

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