Welcome to City Gate LRC
Thank you for taking the first step with City Gate Life Recovery Center. Please set aside 5-10 minutes to fill out this brief form so that we can process your information and reach out to you within 48 hours in order to hopefully schedule a first appointment.

City Gate LRC is currently partnered with the following insurance providers:

Blue Cross Blue Shield
Independent Health
Tricare East/Tricare West/Tricare for Life

Alternatively, City Gate LRC also accepts private pay on a sliding scale based on household income.

Sign in to Google to save your progress. Learn more
Email *
Please provide your FULL name (this should match what is listed on your medical insurance card): *
City Gate LRC therapist teams specialize in four specific areas of focus. Please select one or more of the following, if applicable, according to your need:
Please give us a brief description of what lead you to reach out:
Clear form
Never submit passwords through Google Forms.
This form was created inside of City Gate LRC. Report Abuse