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LifeBack Inquiry Form

First name

Last name

Completing Inquiry Form for:

Phone

Gender

Job Title

If not employed, put "N/A"

Place of Employment

If not employed, put "N/A"

Please give us a brief description for why you are seeking counseling:

Have you ever had counseling in the past? If so, how was your experience?

What is your preferred counseling schedule?

Weekdays (daytime)

Weekdays (evening)

Online-only

We frequently receive requests for evening session. Please note that selecting an evening time may result in a longer wait for your first session.

PLEASE READ AND ACKNOWELDGE: Once you submit the form, your information will be reviewed and we will contact you to schedule your next step.

Each counseling session is $65.00.

If this is an emergency situation concerning your safety, mental health, or the safety of another individual, please STOP NOW and call 911.