Contact Diakon Lutheran Family Life Services

Client Information

Address

Client Phone Number(s)




Services

EAP

Insurance Information

Acknowledgement

By clicking and submitting this form, I verify that all information contained on this form is correct and current to the best of my knowledge. I understand that any information provided is for the purpose of creating a Diakon Family Life Services intake profile and will be kept strictly confidential. I acknowledge receipt of Diakon Lutheran Social Ministries' HIPAA Notice of Privacy Practices, found here: www.diakon.org/PrivacyPractices.asp.


I understand that Diakon Lutheran Social Ministries and Diakon Family Life Services maintain the information provided by me in this form in compliance with all federal and state privacy rules.


I agree to have Diakon Family Life Services contact me to provide the requested services and follow-up. I agree that I provided the information for the purpose of being contacted about the services checked above and understand that contact information and background provided on this form will be used for that pupose only.

  1. Family Life Services
  2. Counseling
  3. Family-Based Mental Health Services
  4. Medication-Assisted Treatment
  5. Addictions Counseling
  6. Psychiatric Services
  7. Specialized In-Home Treatment Services (SPIN)
  8. Trauma-Focused Therapy
  9. Student Assistance Training
  10. Locations


After you click the submit button, a representative from Diakon Family Life Services will contact you within two (2) business days.