New Client Appointment Request
Hi there,

Thank you for your interest in services. Complete this form and I will get back to you as soon as possible to schedule a brief phone or video consultation.

Keep in mind that all the following fields are required to send the form. At the end/completion of the form, you will be able to request a copy of your responses if you would like.

I look forward to speaking with you in the next 48-72 hours.

-Dr. Sam Lustgarten
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Email *
Phone Number *
Full Legal Name *
For example: Samuel David Lustgarten
Preferred Name *
Pronouns *
For example: she, her, hers
Gender *
Sex Assigned at Birth *
Sexual Orientation *
Race and Ethnicity *
Religion/Spirituality *
Date of Birth *
MM
/
DD
/
YYYY
Current Address *
For example: 1600 Pennsylvania Avenue NW, Washington, DC 20500
Are you looking for individual or couples therapy? *
Primary Concern(s) *
Please tell me a little bit about what's been concerning you.
How would you prefer to be contacted? *
Required
Do you consent to leaving voicemails for scheduling? *
What time(s) of the day would work best for therapy appointments? *
I am only able to see clients Monday-Friday from 9 am to 4 pm at this time.
Required
What type of billing/coverage will you be using? *
Please choose one of the following options for payment/reimbursement.

For residents of Wisconsin, I accept Quartz, Dean Health Plan, The Alliance (Student Health Insurance Plan), or Out-of-Network Reimbursement.

For residents of Oregon, I only accept self-pay or out-of-network reimbursement.
How did you learn about the practice? *
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