REQUEST FOR THERAPY SERVICES FULL NAME * First Name Last Name EMAIL ADDRESS * SUBJECT: * TYPE OF SERVICE YOU ARE SEEKING: * INDIVIDUAL THERAPY FAMILY THERAPY CAREER COACHING BUSINESS COACHING OTHER PLEASE TELL US HOW WE CAN HELP YOU. * WHAT ARE SOME GOALS YOU WOULD LIKE TO ACHIEVE? * PHONE NUMBER: * (###) ### #### CAN WE TEXT YOU TO THIS NUMBER? * YES NO CITY & STATE * YOUR AGE: YOUR AGE: 17 to 25 26 to 34 35 to 43 44 to 52 53 to 61 62 to 70 71 and older WHICH THERAPIST WOULD YOU LIKE TO WORK WITH? (These are independent practitioners sharing office space at Lumin). * Anne Wilzbacher, MA, LPC Soula Zaharopoulos, MSW, LISW-CP Dr. Angelica Perez-Litwin, PhD, MBA Please match me to the best fit therapist. INVESTMENT STATEMENT: We are a self-pay practice. We do not accept health insurance, but we do provide the paperwork necessary to submit claims for out-of-network benefits. * Yes, I understand that all services are self-pay. We look forward to connecting with you. A Lumin team member will reach out to you promptly.
