Are you completing this form for yourself or another person?*
Which housing type best describes your living situation?*
Preferred Method of Service*
Preferred contact method (By submitting this contact form you consent to being contacted, which includes our company information.)
Sex (Please note we ask for insurance purposes)*
Pronouns (Select all that apply)*
Race/Ethnicity (Select all that apply)*
Check all services you are interested in receiving:*
Will services be paid out of pocket OR through insurance? *
Will you be using Services through EAP?
If using EAP, please provide the formal letter showing the authorization code, number of sessions authorized, and effective dates.
Please indicate who is the primary policy holder. *
Who is the insurance provider?
Primary policy holder's date of birth
Primary policy holder's sex as indicated on their insurance
Preferred frequency of sessions
How did you hear about us?
Are you a former client of Lighthouse Therapeutic Services?*
Would you like support with any of the following:
Thank you for taking the time to complete our referral form.
We will be in contact with you soon.
