844-LifeChange (543-3242)
GET HELP. CALL OUR HELPLINE 844-LifeChange (543-3242)

Lighthouse Network Application Form

Please fill out the form to be accepted into our Clinician Network. We request a $50 donation to be part of this network. Read our donation page to see where your donation dollars go. You can see all the great benefits of joining the newtwork by reading the Clinician Letter.

New Clinician or Pastor Application

  • Provider Contact Information

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  • Mental Health Services You Offer

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  • Addiction Services

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  • Practice Details

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  • Finances/Fees

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  • If you provide PHP or Residential level of care services,
    please call David Hoskins at 844-Life-Change (844-543-3242) or cell: 954-536-9539.
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  • Please select your state from the options below to determine who your Clinical Liaison will be.
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  • Donation

    A $50 donation is required to be part of the Outpatient Network. Choose which project below your donation will be applied to and once you submit the form you will be taken to PayPal's secure website to complete your donation. Learn more about our projects by visiting our donate page.
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Get help now! Call (844) 543-3242