Appointment Request: Shapiro's Counseling Services, PLLC

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Appointment Request: Shapiro's Counseling Services, PLLC

Sierra D. Shapiro, M.S.

Licensed Psychotherapist

Shapiro's Counseling Services, PLLC

1938 Burdette Street

Suite 222

Ferndale, MI 48220

P: 248-206-5250

F: 248-493-5912

E: sierra@shapiroscounseling.com

W: www.shap-counseling.com

Please answer the questions below to the best of your knowledge:

Today's Date: *

YYYY

Full Name: *

Preferred Name:

Date of Birth: *

YYYY

Pronouns:

she/her/hers

they/them/theirs

he/him/his

Other:

Clear selection

Email Address: *

Physical Address:

(Please be sure to include city, state, and zip code)

Mailing Address:

(If different from physical address)

Phone Number: *

Insurance Carrier:

Note: If your insurance carrier is not listed, I unfortunately do not accept it. Please ask about self-pay rates if you wish to proceed.
*

Aetna (Commercial)

Blue Care Network of Michigan (BCN)

Blue Cross/Blue Shield

Cigna

McLaren Medicaid

Traditional or "Straight" Medicaid

Self-pay

If your insurance carrier is through Traditional or "Straight" Medicaid, please specify if your coverage is temporary and/or if you will be switching to another insurance carrier within the next year.

Please briefly describe why you are seeking therapy services: *

How did you hear about this practice? *

Psychology Today

GoodTherapy.org

TherapyDen.com

Social Media (Instagram, Facebook, etc.)

Practice Website (shap-counseling.com)

Current or Former Client

Other Healthcare Provider/Therapist

Other:

What is your availability for appointments? Please check all that apply.

TUES

WED

THURS

FRI

10 AM

11 AM

12 PM

1 PM

2 PM

3 PM

4 PM

5 PM

6 PM

7 PM

Are you requesting virtual or in-person sessions? (Virtual sessions are conducted in the form of a video call via the HIPAA-compliant version of Zoom.)

Virtual

In-Person

No Preference

Clear selection

Before submitting your appointment request, please read each statement below and select "I Acknowledge" to confirm your understanding:

Establishing Patient-Psychotherapist Relationship: *

I Acknowledge: Submitting this form does not establish a patient-psychotherapist relationship. A relationship is formed only after a formal agreement during a face-to-face meeting or teletherapy session.

Required

Service Provision and Availability:

I Acknowledge: This form submission does not guarantee the provision of services. Availability depends on the psychotherapist’s current client load, scheduling, and service appropriateness for my needs.

Required

Confidentiality and HIPAA Compliance:

I Acknowledge: This form, being HIPAA-compliant, is designed to protect sensitive information to the extent possible. However, as with any online communication, absolute security cannot be guaranteed. Therefore, while some sensitive information is necessary for initial contact and scheduling, I understand the risks involved and agree not to share highly confidential or detailed personal information at this stage.

Required

Emergency/Crisis Situations:

I Acknowledge: In case of an emergency, I should contact emergency services or go to the nearest emergency room and not rely on this form.

Required

Acknowledgement and Understanding:

I Acknowledge: By submitting this form, I confirm that I have read, understood, and agree to the terms outlined in this disclaimer.

Required

Submit

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