Name
First Name
Last Name
Age
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Reasons for Seeking Therapy
Do you have a preference for Day of Week and Time of Day, or would you like a first available appointment?
How frequently do you prefer to meet?
Weekly
Every 2-3 Weeks
Monthly
Every 6-8 Weeks
Quarterly
I prefer to meet:
In Person: Birmingham
Telehealth
Our rates are $150/Assessment and $130/55 minute session. Please select your preferred method of payment.
I plan to private pay
I plan to utilize insurance. Hannah accepts Blue Cross Blue Shield, Tricare, and TELUS Health (Previously BHS).
If you plan to use insurance, what kind of insurance do you have?
How did you hear about Lifeline?
Do you have any questions before we schedule?
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