Litzie Hassell Counseling and Wellness, LLC

Litzie Hassell Counseling and Wellness, LLC Send Message

Who would be receiving care?

Me

Someone else

Your info

First name

Last name

Email

Phone

Name you go by

Date of birth

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

Administrative

Inquiry reason

Referral source

Please share how you were referred to me.

Billing & Payment

Payment method

How do you plan to pay? I accept most Aetna plans. My private pay rate is $160 and I offer a sliding scale to keep therapy accessible.

Out of pocket Insurance I'm not sure yet

Client Preferences

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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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.