Request an Appointment

Helpful Links:

To talk to our patient registration staff directly, call 1-855-272-1653, or fill out our online form below and we will call you to follow up.

Name

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Phone Number

Date of Birth (Format: YYYY-MM-DD)

Do you have health insurance?

Do you have supplemental/secondary insurance or medical assistance products (PerformCare, CCBHO, Etc)?

Are you open to an Online/Telehealth appointment?

Please select the preferred location for appointments

Please select the preferred provider

Reason for seeking treatment?

Please attach the following:

I confirm that I would like to schedule an appointment with LiveUp Counseling

Agree