Important Instructions:

You must complete the entire form. This form is embedded so you will need to scroll  WITHIN the blue area or text to see additional questions.

If you are having trouble completing the form on this page try clicking here to view it in a different window.

Keep scrolling within the blue area above until you complete all the questions! There are several sections and you will need to click a "Next" button for each section. You will know you are done when you click the "Submit" button at the end of the form.

You should see a message that says, "Your intake form responses have been successfully submitted!"

If you need to fill out an additional form for another family member there will be an option to submit another response.

If you are having trouble completing the form on this page try clicking here to view it in a different window.

If that still doesn't work please send us an email at info@lighthousecomplexcare.com

Thank you!