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Search for:
Home
Our Therapists
About
Services
Insurance
FAQs
Contact
Home
Our Therapists
About
Services
Insurance
FAQs
Contact
Search for:
Let's talk.
Let's talk.
Contact
Elizabeth Lugo
2024-10-30T20:22:50+00:00
First Name:
*
Is this a minor?
*
Yes
No
If yes, parent or guardian full name:
Presenting Problem:
*
Anxiety
Depression
PTSD
Relational Issues
LGBTQ Issues
Grief
Previous Trauma
Substance Use
Parenting
Unknown/Unsure
Insurance:
*
Aetna
Cigna
United Healthcare
Oscar
Oxford
EAP
Other
Self-Pay
Last Name:
*
Phone Number:
*
Email Address:
Preferred Days:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Times:
*
Additional Comments?
Consent:
*
Disclaimer: The form provided on this website is for general inquiries, appointment requests, and informational purposes only. It is not intended for use in emergencies or as a substitute for direct, professional mental health advice, diagnosis, or treatment. Confidentiality Notice: The information you provide will be kept confidential to the extent permitted by law and used solely to respond to your inquiry or assist in scheduling an appointment. Please do not include sensitive information, such as detailed medical history or personal issues, through this form. Limitations of Online Communication: Submission of this form does not establish a therapist-patient relationship, nor does it guarantee immediate response or availability of services. For urgent matters, please call our office directly or contact emergency services. By submitting this form, you acknowledge and agree to these terms.
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