Intake Form

Intake Form
Beacon of Inner Healing Logo

Beacon of Inner Healing, LLC

Lara Dietrich, LCSW, PATP

441 East Market St. Suite 6208, York, PA 17403

(717) 610-0649

INITIAL INTAKE INFORMATION

Welcome to Beacon of Inner Healing in York, PA, the practice of Lara Dietrich, LCSW. This secure intake form helps us understand your needs to provide personalized care. Some sections may cover sensitive topics like trauma and family dynamics. You may opt out of any questions, download a paper form to submit in person, or request a verbal questionnaire.

Rest assured, your submission is encrypted and securely stored to protect your personal data. If you have questions or need help, contact us at (717) 610-0649 or intake@beaconinnerhealing.com.
I look forward to supporting your healing journey.

Personal Information

Let’s start with the basics. Please provide your contact details and other general information so we can get to know you better.
Name
Name
First Name
Last Name
How you identify yourself (e.g., he/she/they/them).
Select your date of birth.

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