Living Lotus Family Therapy, Inc

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Please share as much as you care to share.

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What kind of care is being sought?

Individual Psychotherapy Family Psychotherapy Assessment/Evaluation Parent Consultation/Training Not Sure

Billing & Payment

Fee Inquiry

Living Lotus Therapy is an Out-Of-Network (OON) Provider.

Insurance details

If you have a PPO Insurance and would like for us to check your benefits, please share the insurer's name, dob, and member ID.

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Client Preferences

Preferred modality

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.