JL Family Services Ltd. | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

What is your preferred method of contact?

Select how you’d like us to follow up about your therapy inquiry.

Text Email Phone Call Client Portal Message Other

Reason for care

What kind of care is being sought?

Individual Therapy Couples Therapy Individual and Couples Therapy Family Therapy

Billing & Payment

Please provide your payment information below:

Include your primary insurance carrier, secondary insurance (if applicable), or the EAP company you plan to use. If you’re unsure, feel free to list whatever information you have available

Limited to 600 characters

Client Preferences

Preferred appointment times

Please share 2–3 specific days and times that work for an intake call.

Morning Afternoon Evening Weekend

Preferred clinician

Select a clinician from the list

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Alternate Therapist Qualities

If your preferred therapist isn't available, what qualities or specialties would you like in another therapist?

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.