Enroll

Please complete the form below to join LifeWorks.

*At LifeWorks, out of respect for your privacy, we keep all information shared with us confidential.

Parent Information

* Indicates required field

Parent 1 - Name *

First

Last

Email *

Phone Number *

Parent 2 (optional) - Name *

First

Last

Email *

Phone Number *

Student Information

Student Name *

First

Last

Student Email *

Student Phone Number *

School *

Grade *

Subject(s) Needed *

Is there anything else you would like us to know? *

How did you hear about us? *

Billing Information

All payment information is securely stored. Invoices are emailed out at the end of each week.

Name *

First

Last

Email (if different than above) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Credit Card Number (VISA or Mastercard) *

Billing Policies

Expiration Date *

* Billing takes place at the end of each week.
* We require 24 hours notice for reschedules and cancellations. (Unexpected illness and family emergencies excepted).
* If less than 24 hours notice is given a 50% fee will apply. If no notice is given, missed sessions are billed at our regular rate.

Agreement to Terms *

Yes, I have read and agree to the policies above.

Submit

Welcome!

Please complete the form below to join LifeWorks.

Parent Information

Student Information

Billing Information

Billing Policies

Corte Madera

Mill Valley

CONTACT US

UPDATE BILLING

​Welcome!

Please complete the form below to join LifeWorks.

​Parent Information

Student Information

Billing Information

Billing Policies

Corte Madera

Mill Valley

CONTACT US

UPDATE BILLING

Welcome!

Parent Information