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.

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

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, you are welcome to discuss these matters with an LCL clinician.