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Erika Piloto, LCSW -Psychotherapist at Lifeway Counseling & Consulting, LLC
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Intake form
Help us serve you better
Name
*
Email address
*
What type of therapy services are you seeking?
Please select at least one option.
Individual Therapy
Couples Therapy
Family Therapy
Group Therapy
What is your primary reason for seeking therapy?
Have you previously received any form of therapy?
Select
Yes
No
What are your goals for therapy?
Do you have any mental health diagnoses?
Please select at least one option.
Anxiety
Depression
PTSD
Bipolar Disorder
None
What is your preferred method of communication?
Select
Email
Phone Call
Text Message
Are you using your insurance coverage?
Please select at least one option.
Yes, I have insurance coverage
No, I plan to pay out of pocket
How did you hear about our services?
Please select at least one option.
Referral
Social Media
Search Engine
Website
What is your availability for sessions?
Which service or services are you interested in?
Please select at least one option.
Anxiety management
Body image and Self-Esteem
Therapy for depression
Therapy for relationship and attachment issues
Therapy for grief
Therapy for life transitions
Therapy for eating disorders
Therapy for trauma
Therapy for college students
Therapy for women
Career counseling
Chronic stress & burnout
Supervision & consultation for clinicians
Couples counseling
Family therapy
Additional questions or comments
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