Family Life Consultants
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Insurance Information & Forms
Use this form and the business office or a therapist will reach out to schedule your first appointment.
* Who will we bill for services?
I will use my insurance
I have an EAP
I will Private Pay
I'm not sure
* Sex assigned at birth
Male
Female
Gender Identity
Male
Female
Transgender Male
Transgender Female
Transgender (as non-binary)
Non-Binary
Gender-Queer
Two-Spirit
Questioning/Not sure
Choose not to disclose
Preferred Method of Contact
Phone
Text
Email
* What type of session are you looking for?
In Person
Telehealth
First Available
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Other Questions or Comments?
For all other inquiries use the below form.
You may also call us at 618-345-9536 or email us at familylifeconsultants@hotmail.com
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