Welcome to Life Connections Counseling Services. 

Thank you for your interest for the quickest response, please complete the following inquiry. This inquiry will be sent automatically to our Intake Department and a specialist will be in contact as soon as possible.

*Please note that our Intake Department is available 9am-3pm Monday-Thursday. All inquiries will be responded to in the order in which they were received. Please only submit one request as duplicate requests will result in a delay in response.

 

    Your Name (required)

    Your Email (required)

    Your Phone Number

    Name of client seeking services:

    Age of client seeking services:

    Type of Insurance (required)

    Type of Services (required)

    Reason for seeking services:

    Provider Preferences:

    How did you hear about us?

    Best time of day to call

    This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.