Appointments| Lebanon Valley Counseling

Intake Request

PLEASE NOTE: This form must be filled out by the person (age 14+) requesting therapy.
We will follow up via email within 1-3 days. If you do not receive a response within 72 hours, please email us.

Full Name

Phone

Date of Birth

Address

Preferred Locations?

Online (teletherapy)

Lebanon Office

What is your general availability for appointments? Note that limiting availability to evenings will result in a longer wait

Do you have a prefered therapist or style of therapy?

Primary Cardholder's Name:

If you plan to use your health insurance benefits OR plan to submit your bill to your insurance for reimbursement of out-of-network services, please upload a picture of the front and back of your insurance card.

Insurance Card FRONT

Upload File

Insurance Card BACK

Upload File

What brings you to seek therapy at this time?

By submitting this form, you attest that you are the person seeking therapy and that all the information provided is yours; you agree to receive responses via email, phone call, and/or text message and give us permission to leave a voicemail with our information; you understand that availability of your preferences or any appointment at all is not gauranteed.

Thanks for submitting!

Intake Request PLEASE NOTE: This form must be filled out by the person (age 14+) requesting therapy. We will follow up via email within 1-3 days. If you do not receive a response within 72 hours, please email us.

Contact Us

Intake Request

PLEASE NOTE: This form must be filled out by the person (age 14+) requesting therapy.
We will follow up via email within 1-3 days. If you do not receive a response within 72 hours, please email us.