Contact us to get scheduled today! hello@leadlightcounseling.com616.217.9934 Name * First Name Last Name Phone (###) ### #### Email * Date of Birth (of client) * Insurance Provider * If you don't see your insurance listed, please select private pay to discuss options available to you. ASR Aetna Blue Cross Blue Shield Blue Care Network Cigna Cofinity Priority Health Priority Health Medicaid Molina United/Optum Blue Cross Complete Priority Health Medicaid No Insurance- Private Pay Contract ID Number If you have your insurance ID number, please include that here. This helps us be more efficient. Location Holland Cascade Relationship to Client (if a minor) Tell us a little about how we can help * Type of Therapy Individual Couples Child/Play Other helpful information (Faith preference, Multiple homes, Clinician gender preference, Languages spoken in the home) How did you hear about us? Thank you! Someone from our office will be with you shortly.
