Online Intake Application

If you or someone you love is interested in receiving services from East Texas Lighthouse, please complete and submit the form below. Someone from our team will follow up and walk you through next steps.

About You

Your Name(Required)

First Name Last Name

Your Street Address

City

County

State

Zipcode

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Your Email Address

Your Phone(Required)

Date of Birth

Gender

Female

Male

Not Listed

Prefer Not To Say

Military Service

Yes

Emergency Contact Name

Emergency Contact Phone

Eye Physician Name & Location

Your Comments/Questions