New Client Inquiry Form

If you have any questions about the information requested on this form, please contact admin@lotuscounselingservices.org.

Legal name

Preferred name

Date of Birth

State of Residence

Email Address

Phone Number

Are voicemails okay?

Yes No

Are text messages okay?

Yes No

Preferred Method of Contact

Email Text Phone Call

Note: Appointment and documentation reminders are sent via email.

Please briefly describe what you want to target in therapy.

Name of Partner

Date of Birth of Partner

State of Residence of Partner

Email address of Partner

Phone Number of Partner

Are voicemails okay? (for partner)

Yes No

Are text messages okay? (for partner)

Yes No

Preferred Method of Contact (for partner)?

Email Text Phone Call

You'll typically hear from us within a few hours to begin the matching process.

Would you like to get a head start on your registration by providing a few additional details? This process will take less than 5 minutes.

Yes No

Do you have an EAP authorization letter or email?

Yes No

Upload a picture of the EAP authorization letter or email.

Add file

Please upload a file

Please provide the following information: 1. Name of EAP provider. 2. Telephone number of EAP provider. 3. Authorization number that was provided to you when your sessions were authorized. 4. Number of sessions authorized. 5. Date range of authorization.

Add another insurance plan

Upload a picture of the FRONT of insurance card for EACH insurance plan you have.

Add file

Please upload a file

Upload a picture of the BACK of your insurance card for EACH insurance plan you have.

Add file

Please upload a file

Upload a picture of your driver's license or state issued ID. Upload a picture of your partner's ID also if you are requesting couples therapy.

Add file

Please upload a file

What is the name of the person and their profession that referred you?

Please explain how you heard about us.

Your information will be encrypted.