Secure Inquiry Form

Please fill out the confidential form below so that we can better understand your needs and match you with one of our therapists. We will contact you on the next business day to answer any questions you may have and set up your first visit. If you want to connect with us more quickly give us a call at 855-245-LIFE.

First Name

* Required

Last Name

* Required

Please indicate your interest with Fuller Life:

* Required

Phone Number

What kind of phone is your primary phone number?

* Required

We have various fees for different levels of licensure & education. Please select your preference:

* Required

Please indicate if you prefer to do therapy via telehealth or at either of our four locations in Houston.

* Required

Would you like to receive relational and mental health resources from Fuller LIfe?

* Required

How did you hear about our services?

* Required

If other selected, please specify.

Were you referred by one of our therapy assistance partnership program (TAPP) organizations? (Some may assist with the fee for therapy services.)

If referred by one of our therapy assistance partnership program (TAPP) organizations, please specify the organizational name

Please share anything else you want us to know.

Please leave this checkbox blank