Lotus Counseling Services, PLLC

Who would be receiving care?

My partner and me

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Your info

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Phone

Name you go by

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Pronouns

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Are voicemails okay?

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Are text messages okay?

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Administrative

Driver's license upload

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How did you hear about us?

If referred by a provider, please list the name of the provider below.

Do you give us permission to contact the provider that referred you in order to coordinate your care?

Yes, you may contact my referral provider. No, you may not contact my referral provider. I was not referred by a provider.

If you have any questions for our admin team, please write them below.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.