First appointments for therapy are made over the phone. Call (850) 841-7733 before proceeding.
Intake Forms for all minors MUST be filled out and signed by parents or guardians before first appointment.
Scroll to the bottom of the page for more information about your first visit.
1) Choose appropriate New Client Intake Forms from the list below
2) DOWNLOAD and save form onto your computer
3) Fill out and save on your computer
4) Attach completed form to an email to your therapist prior to first appointment (list of therapists’ emails below)
Child or Teen Client – Death or Loss Therapy Needs
Child or Teen Client – Divorce Therapy Needs
Child or Teen – General Therapy Needs
Adult Client – General Therapy Needs
Adult Client – Death or Loss Therapy Needs
Sliding Fee Scale 2020
Telemental Health Informed Consent for video or phone sessions
Lee’s Place therapist email addresses to send completed forms:
Karen Lockard – email@example.com
- Everyone must have an appointment to be seen by a therapist.
- You do not need a doctor’s referral to call and make an appointment.
- There is no charge for the first appointment. Additional appointments are scheduled on an individual basis with your therapist.
- Fees are based on your income and number of dependents. See our Sliding Fee Scale below to determine your fee structure.
- Choose the Intake Forms from the lists above that apply to you. PRINT, then fill out to bring with you, or you can fill it out at Lee’s Place when you arrive for your initial intake appointment (please arrive early to fill out forms at Lee’s Place).
- We do not file or take insurance. We can include a diagnosis code on your invoices if your insurance company allows you to submit invoices for reimbursement after you have paid them.
- Each appointment must be paid for at the time of service. Go to Client Payment page for more detail
Lee’s Place is a nonprofit grief, loss, and trauma therapy center providing licensed, specially trained therapy to children, teens, adults, and families in need, on a sliding fee scale to ensure everyone can get the help they need when they need it. If you or someone you know needs help coping with any type of loss or trauma please call today.
We rely on donations from individuals and businesses and appreciate your support of our mission.