THERAPY REQUEST FORM

Now offering ONLINE SCHEDULING for ALL NEW PATIENTS!

Please fill out our therapy request form and a member of our team will get back to you as soon as possible.

If you would rather call us then don’t hesitate to call us at 804-477-6137.

Therapy Request Website Form

Schedule Your Appointment!

Intake Outpatient Therapy Appointment

Intake Mental Health Skill Building Appointment

First Name

Last Name

Phone

Second Phone Number (If Applicable)

Free Text

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Date of Birth

Which Office Do You Want to Be Seen At?

530 E Main St, Richmond, VA 23219 - Virtual

I prefer virtual/tele-therapy.

If only tele-health is available would you be open to utilizing tele-therapy?

Yes

What Type of Insurance Do You Have?

Free Text

If You Have Medicaid, Please Let Us Know What Type of Medicaid Do You Have.

Therapist Gender Preference

Male

Female

No Preference

Why are you seeking therapy?

How would you like to be contacted?

Phone

Text

No Preference/All of the Above

Any additional information you feel we should know?

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

OVERVIEW

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Contact

CONTACT

Telephone: (804) 477-6137

E-mail: info@lflmhss.com

LOCATION

530 E Main St, Richmond, VA 23219

CONNECT

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