Peaceful Living Mental Health Counseling, PLLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Administrative

Select any of the questions you may have below. We'll make sure we get those answered so you have all the info you need to make a decision.

Questions about therapy costs Insurance and coverage questions Ready to schedule my first appointment Check therapist availability Request a free consultation call Questions about treatment approaches or specialties None, I'm ready to start!

Referral source

How did you find us?

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment method

We are an out-of-network practice and do not accept insurance directly. If your insurance plan includes out-of-network benefits, we can provide a superbill for possible reimbursement. Session fees range from $205–$350 per session, depending on the provider. Do you understand and accept this fee arrangement?

Yes No

Do you plan to use your out of network benefits?

Yes No Not sure if I have that but I'd like to find out (make sure to include your insurance info on the next questions!)

Insurance card upload

Upload a photo of your insurance card

Yes No

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred location

Any other preferences that are important for us to know?

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.