Information Request Form
Please feel free to complete the form below to learn more about our services. By clicking submit, you are agreeing to have us communicate with you via phone, voicemail, email or text, which may not be secure.
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Email *
Name *
Phone Number *
Seeking Services for: *
Age of Potential Client *
Insurance Information (Insurance company and plan. Specify if Medicaid or Medicare) *
Please Note: At this time, we DO NOT participate in any insurance plan including Medicaid, and we have OPTED OUT of Medicare. We will provide you with a receipt which has all of the information your insurance company will require for you to submit for out-of-network reimbursement (If you are eligible). Our services and rates are available at: *
Please provide a brief description of your request *
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Good Life Center for Mental Health, LLC.