LiveDifferent Pre-Intake Form

We’re so excited you’ve chosen to join us at CrossPurpose. Please complete the LiveDifferent Recovery & Counseling Services pre-intake form below to get started.

Your privacy is important to us. The information collected in this survey will be used solely for internal purposes to improve our services and support. We will not sell, share, or distribute your personal information to any third parties without your explicit consent. All responses will be kept confidential and stored securely. If you have any questions about how your information is used, please contact us. By completing this survey, you acknowledge and agree to these terms.
Contact Info
Please enter your 10-digit phone number with no dashes or spaces (e.g. 7452145852)
Address
Demographics
Please enter just an amount, with no symbols (e.g. 22.50)
Health Information: CrossPurpose currently accepts Medicaid and is in the process of expanding coverage to include additional insurance providers for behavioral health services. These services encompass recovery coaching, group coaching, counseling, and psychosocial education groups. We collect this information to analyze data and make informed decisions based on collective responses. Please be assured that all information provided is strictly confidential and will only be used for billing and data analysis purposes. 

Please Note: If you do not have insurance or have insurance other than medicaid, services provided to you are 100% free. 
Service Needs/Requests
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Contact Information