Outpatient Therapy Referral Form
By filling out this form, you agree to have a member of LIV's staff contact you for further information regarding your interest in Outpatient Therapy Services. ***Initial appointments will be scheduled beginning in January 2025.
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Funding Information
Please Select
Self-pay
BCBS
Cigna
Medicaid
United Health Care
Are you currently living in an LIV Sober Living House?
Yes
No
If 'Yes' please select a location.
Please Select
Jenni House
Brandi House
Placid House
Linda House
Restoration House
Transformation House
Tell us a little about what your current concerns are or what you would like to work on in therapy.
Would you prefer In-Person or Telehealth appointments?
In-Person (Hillsboro Location only)
Telehealth
Either In-Person or Telehealth
Appointments are Monday-Friday 9am-5pm. When are you available for appointments? Select all that apply.
Morning
Afternoon
Evenings
Submit
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