*

I understand that payment is due at time of service. Dr. Shapiro is not currently in-network with any insurance carriers. I will be provided with a superbill to submit to my insurance company for out-of-network reimbursement

*

Completion of this form does not establish a patient-doctor relationship and does not guarantee treatment. Please call 911 if you are experiencing a psychiatric or medical emergency

Full Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What issues would you like to address? *

Check all that apply

Substance use

Depression

Anxiety

Attention deficit

Anger

Impulsivity

Mood swings

Other

Mental health history *

Check all that apply

Currently in therapy

Currently taking psychiatric medication

History of psychiatric hospitalizations

History of suicide attempt

History of self-harm

Neurological or genetic disorder

Other

Which treatment mode(s) are you interested in?

Check all that apply

Medication

Psychotherapy

Mindfulness

I'm not sure