Download and print the appropriate form below.
- Please complete the form and bring it with you to your appointment. We ask that you arrive 10 minutes early for your appointment.
- Please bring your insurance card AND/OR income verification information to your appointment.
- We will also collect the payment for your session at the time of the appointment. At the Lenhart office, we accept cash, check, credit/debit, Flexible Spending, and Healthcare Savings Account cards. At the satellite offices (First Christian Church Downtown, South Side Christian Church, and Mt. Pulaski First Christian Church), we can accept cash and check. If you would like to use a credit/debit, HSA or FSA card at the satellite offices, please download and complete a credit card authorization form and bring it with you to your appointment.
- If you are applying to use the sliding scale, please download the Income Verification Form and bring it to the appointment along with the requested documents. (Please note: failure to provide documentation before your appointment or bringing it to the appointment will result in being charged the full standard rate of $150).