Consultation Request Form
Welcome to Living Purpose Mental Health Counseling, PLLC. We want to thank you for considering us in your journey towards your Mental Health and well-being. Please fill out the following questionnaire to help us understand your needs and how we can best support you. 

At our practice, we believe that everyone deserves access to quality mental health care, regardless of their financial situation. That's why we offer a range of options to make therapy affordable, including sliding scale fees, Probono Scholarships. We welcome Loveland Foundation Vouchers, work with Open Path Collective services, and now accept some major insurances. Our commitment is to ensure that therapy is within reach for those who need it most. 

This is a request for a free, 15-minute consultation. 

Please note, we are a fully Telehealth practice, licensed to practice in the states of New York, New Jersey, and Connecticut. 

Thank you again, for your consideration.
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Preferred Language spoken *
Full Name *
Date of Birth *
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Email *
Phone Number *
What state do you reside? *
 Please select your primary insurance from the list.
 *
**IMPORTANT**
***Please email us your insurance card, front and back!  (If you are not using insurance, you can upload your drivers ID or any state ID).***

Email:  contact@livingpurposementalhealthcounseling.com
Subject line: Insurance card or Drivers ID (Your Name) 
Please enter your primary insurance member ID, or "N/A" if you’re not using insurance. *
Enter your primary insurance group number or "N/A" if not using insurance/don't have one *
FULL NAME of the primary insurance policy holder or "N/A" if not using insurance. *
What are you looking to work on together?
 *
Do you have any open CPS cases? *
Any other information/concerns?
 *
Reminder:
***Please email us your insurance card, front and back!  (If you are not using insurance, you can upload your drivers ID or any state ID).***

Email:  contact@livingpurposementalhealthcounseling.com
Subject line: Insurance card or Drivers ID (Your Name) 

Thank you for your time to completing the questionnaire! A member from our team will reach out to you within the next 24-48 hours.  
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