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LSI Therapy and Behavioral Health Intervention Services Intake Form

Call Central Intake at 888-457-4692 with questions

Client Information


Program Type

Parent Guardian Information

If biological parents are not married or child is in foster care/placement *bring custody agreement/court order stating who has leagal guardianship to 1st meeting.*

Referral Information

Who referred you to Lutheran Services of Iowa? OR Please give your information if you are the referral source.

Payment/Insurance Information

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