Evolving Lives LLC (Contact & Referral Form)
Thank you for contacting Evolving Lives. As of Jan 1, 2025 Evolving Lives LLC will be transitioning to a virtual therapy practice, allowing us to extend our reach and serve more individuals across the entire state of Kentucky.  Our virtual therapy practice offers convenient, confidential, and accessible mental health support from the comfort of your home. We are a multi-disciplinary team that works together to provide a holistic therapeutic approach in treating each person. 

Contact us: 

Evolving Lives LLC
P.O. Box 394
Bowling Green, KY 42101
Phone: 270-495-1222
Fax: 859-209-6504

If you are interested in services, please complete the form below:

If you are in need of emergency services, please call 911 or contact your local law enforcement. National Suicide Prevention Hotline 1-800-273- TALK (8255)
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Email *
First Name: *
Last Name: *
Phone Number *
Who are you completing this form for? *
If other, what is your role, please provide your contact information (phone, email, best method of contact)
Please enter the name of the prospective client, if different than above: (First, Last Name)
DOB *
MM
/
DD
/
YYYY
(Contact information of legal guardian) If the person's is under the age of 18
Gender (Optional)
Reason for the referral (What is the presenting problem?) *
Required
If other was selected, please describe below 
What Services are you interested in?
If other was selected, please describe below 
(Insurance information)

Please note, if you are not using insurance and would like to self-pay, write N/A and select below.
*
Self-pay *
By selecting self-pay, I understand that the per fee rate is $85 and will be due at beginning of each rendered service.  *
If you have a Therapist preference please choose below:

 Please note some Therapist may have a current waitlist. 
 *
We provide a supportive space for individuals seeking affordable counseling services, staffed by master's level student interns under the supervision of licensed professionals. Our interns bring fresh perspectives and enthusiasm, offering evidence-based therapy tailored to your needs. If you are interested in receiving counseling services via a therapist intern please select below (Please note: availability of each therapist intern may depend on schedule, etc. )
Any additional question or information:
 I understand that Evolving Lives is a virtual therapy practice *
Thank you for contacting us! Evolving Lives Team 
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