Let’s Get You Scheduled!

We’re excited to begin your therapy journey, please complete the form below.

We will verify your insurance benefits prior to scheduling. Please allow at least 48 hours to verify your insurance. For any questions or to speak to our Care Coordinator call us directly a (904) 342-3349.

Please email a copy of your insurance card front/back to care@maraslighthouse.com

Name

First Name

Last Name

Phone #

(###)

###

####

Email Address

Who are the services for?

Please indicate: Self, Child, Spouse, Other

Patient's Date of Birth

Patient's Mailing Address

Please note if primary has a different address in the field below.

Insurance Information

Please email a copy of your insurance card front/back to care@maraslighthouse.com Please include the insurance information below for us to complete your verifications. If you are self pay - please note "Self Pay."

Insurance Company's Name

Please add the name of the insurance company

Member ID Number

Group ID Number

Are you the primary on the insurance?

Primary's Name & Date of Birth

Primary's Mailing Address

if primary has a different address

Sponsoring Employer

If using EAP you will need to request the referral be faxed to our office (904-562-3359) or listed under Shamara Gibson/Mara's Lighthouse Counseling Center

Have you been therapy before?

Yes

What are your presenting needs?

(i.e. anxiety, sadness, stress, trauma, substance abuse, boundaries, relationships) This is completely confidential and will be used to match you with a therapist just for you.

Are you looking for in person or virtual sessions?

In Person

Virtual

Message

Please note the best day and time for your sessions (i.e. morning, afternoon, evening)

Referred By

What are you looking for in a therapist?

We will do our best to match you with a therapist based on your preferences (age, specialty, experience).

Mara's Lighthouse Counseling center, LLC.

12086 Fort Caroline Road

Suite 201

Jacksonville, FL 32225

Let’s Get You Scheduled!

Mara's Lighthouse Counseling center, LLC.

12086 fORT CAROLINE RD. SUITE 201, JACKSONVILLE, FL 32225

Phone: 904-990-8105

Fax: 904-562-3359

Email:INFO@MARASLIGHTHOUSE.COM

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