Form Form

New Client Application Form

Please fill out this form completely.

Lincoln Office or Yuba City Office

Choice of Counselor at Lincoln Counseling Center

Client's Name

If client is a minor please state their age.

Insured persons name, if different than client

Insured person's ID number

Insurance Company

name of company, authorization number, claims address, Insured ID number if not listed above.

Insurance Authorization Number

Claims Address for Insurance Billing, (not the one on your card)

Your best contact email address

Your best contact Phone Number

Issues to be addressed

Best time of day for appointment-

Yvonne Sinclair LMFT-Lincoln Office hours on Tuesday (not accepting new clients in Lincoln at this time)
Yvonne Sinclair LMFT-Yuba City Office hours on Monday, Wednesday, and Thursday
Lanee Weesner LMFT-Lincoln Office hours (contact her for times and days)

Merchant Services
Note: All prices in US Dollars
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