Intake

Our intake process is designed to gather important information about you, your current situation, and your needs. This information will help us match you with the best counselor or program to support your unique journey to recovery and well-being. Once you submit the form, our team will review the information and reach out to you to schedule your first appointment. We are committed to making this process as smooth and comfortable as possible for you.

Get Started

Fill out the intake form below to begin your journey with Light of Life Recovery and Wellness Services. We are here to support you every step of the way.

Full Legal Name *

Date of Birth *

Assigned Sex at Birth *

Male
Female

Preferred Pronouns *

She/Her/Hers
He/Him/His
They/Them/Theirs
Other

Ethnicity *

Not Hispanic or Latino
Hispanic or Latino

Phone Number *

Email address *

Known Medical Conditions *

Previous Therapy/ Counseling Experience *

Yes
No

Current Mental Health Concerns *

Goals for Therapy *

Additional Thoughts/Concerns *

Start Your Journey to Wellness Today

Take the first step towards a healthier, more fulfilling life by filling out our intake form.