New Client Contact Form

Thank you for contacting David Shapiro, Ph.D. as a possible new client (or on the behalf of someone else). We are pleased that you are taking advantage of this new online contact form, which is secure, encrypted, and easy to use. This online form helps us efficiently gather some initial information which allows us to establish new clients in our system and to check insurance benefits. We will then call to answer questions and possibly schedule an initial appointment. Please fill in the information below for whomever the potential client is (i.e. possibly yourself, or a family member).

Potential Client Information

First Name *

Middle Initial *

Last Name *

Date of Birth *

Street Address *

City *

State *

Zip Code *

Phone Number *

Secondary Phone Number

Email Address *

Do you have health insurance that you would like to use for this therapy? *

Name of Medical Insurance Company (if applicable).

Is this through an employer? If so, what is the name of the company?

On your insurance card, what is the phone number listed for providers to call (which could be called Provider Services)? 🛈

On the insurance card, what is the number listed for Member Services?

Type of Coverage

Member ID #

Group Number

Which describes the potential client's relationship to the person who is the primary insured on this insurance (i.e. through their work, or their own individual coverage)?

Self

Child

Spouse

Domestic Partner

If the primary insured is someone other than the potential client, please provide the following information for that person.

First Name

Middle Initial

Last Name

Date of Birth

Street Address

City

State

Zip Code

Phone Number

Basic Clinical Information

Please describe the reasons for seeking therapy. *

How did you find Dr. Shapiro as a potential Psychologist?

What would you and/or other family members ideally like for the outcome of this therapy?

Preferred Meeting Times for First Appointment

Dr. Shapiro sees clients from 12 PM to 10 PM on Mondays and Tuesdays, and 12 PM to 5 PM on Wed-Fri. Are there particular times that would be best? If so, please give some information about what days and times would be most convenient.

Thank you for taking the time to provide this information. We will call you to followup in the next day or so. We look forward to helping you.