Contact us to get scheduled today! hello@leadlightcounseling.comPhone: 616.217.9934Fax: 616.616.6675 Client Name * First Name Last Name Date of Birth (of Client) * Parent or Guardian Name (if applicable) First Name Last Name Phone (###) ### #### Email * 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 Subscriber's Date of Birth * Contract ID Number If you have your insurance ID number, please include that here. This helps us be more efficient. Location Holland South Holland North Cascade Virtual Relationship to Client (if a minor) Tell us a little about how we can help Type of Therapy Individual Couples Child/Play Family If prospective client is a minor, is there shared legal custody between Parents/Guardians? Our policy is that anyone with shared custody of a minor consents for services. No Yes 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.
