LCL MA | Clinical Services Intake (Online)

Only fields marked with an asterisk(*) are required. Please complete this entire form if you haven't provided the information to us already on a previous signup form. If you've completed an intake before, please just update any new information you might have to keep our records current.

Demographic and Health information is for your confidential clinical record, and not used for “marketing” purposes. LCL never shares our records with any outside entity unless you ask us to do so (e.g., you provide written consent to send our clinical report to an outside provider).

Skip any questions that are not relevant to you. Information submitted is secure and confidential.

You can remain anonymous by providing a false first name and last name Anonymous.
Contact Information
Consultation Info
Click Here to View other Free & Confidential LCL MA Groups you might be interested in.
Demographic Info
Responses are NOT required. We ask for the information below for statistical purposes and to measure our organization's reach. We keep all information confidential and secure.
Required format: MM/DD/YYYY
Health Information
Responses are NOT required. The information below helps our clinical staff prepare for your consultation and provide followup services as needed.

By submitting this form, you agree that you have read and understand the LCL "Information for New Clients", available via this link. You also understand that if you are referred to an outside provider, LCL will disclose relevant info to the provider.

If you have any questions or concerns, please email