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Make An Appointment with I Ola Lāhui
Aloha. Mahalo for your interest starting therapy with us. Please complete this form and a member of our team will contact you for more information to understand what you're looking for and get you connected with a provider. If you have any questions in the meanwhile, please see our Frequently Asked Questions on our website or call us at (808)525-6255.
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Name
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Date of Birth
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Address
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City, State
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Zipcode
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Email address
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Preferred Phone Number
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Other Phone Number
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Insurance Information
Primary Insurance Carrier
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Any Additional Insurance Coverage?
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Clinical Information
How did you hear about us?
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Reason for Therapy
Depression, sadness
Anxiety or worry
Experienced a recent change
Substance use
Trauma
Couples
Behavior Concerns
Parenting or Family
Aging Issues or Caregiving
Psychosis, Schizophrenia
Other:
Additional Reasons for Therapy (Chronic Disease & Lifestyle)
Diabetes
Hypertension
Chronic pain or headaches
Epilepsy
Sleep Concerns
Weight Management
Tobacco Cessation
Stress Management
Other:
Location Preference (In Person, Telehealth, Mixed)
In Person - Honolulu
In Person - Maui
Telehealth
Mixed In Person and Telehealth
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Availability (Days of the Week and Times)
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