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Out of respect for your privacy we keep all information shared with us confidential.

Parent Information

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Parent 1 - Name *

First

Last

Email *

Phone Number *

Parent 2 - Name (Optional) *

First

Last

Email *

Phone Number *

Student Information

Student Name *

First

Last

Student Email *

Student Phone Number *

School *

Grade *

Type of Support Needed *

Additional Information (Optional) *

How did you hear about us? *

Billing Information

Name on Card *

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Last

Credit Card Number (VISA or Mastercard) *

Expiration Date *

Billing Email *

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

* Billing takes place at the end of each week.
* We require 12 hours notice for reschedules and cancellations. (Unexpected illness and family emergencies excepted).
* If less than 12 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 *

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

Enroll

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UPDATE BILLING

​Welcome!

Please complete the form below to join LifeWorks.

​Parent Information

Student Information

Billing Information

Enroll

GET IN TOUCH

UPDATE BILLING

Welcome!

Parent Information