New Patient Inquiry Information

Thank you for your interest in scheduling an appointment with Dr. Salvatore. Please fill out the information below. Once this information has been processed, you will be contacted by Dr. Salvatore or his staff.

(This information is considered private and confidential. It will be secured by digital encryption technology and will not be shared with any third parties. If you would prefer, you may instead send your inquiry and relevant information to
Sign in to Google to save your progress. Learn more
**Please note that while Dr. Salvatore's practice is often full, he will do his best to respond to your inquiries via email.**
Name *
If you are filling out this form on behalf of someone else, please include both names.
Cell number *
Feel free to list cell, work, home numbers where you would like to be contacted.
Home number
Email address *
In order to work with Dr. Salvatore, you must be comfortable exchanging emails for the purpose of scheduling appointments, requesting refills, and communicating about other miscellaneous and straightforward issues. There are, of course, matters which are more effectively communicated in person or over the phone; email is still useful in scheduling such conversations. Please share your email address below.
Age *
Dr. Salvatore's practice is limited to patients 18 and over.
Gender *
What are your current symptoms? Please be as specific as possible. *
For example: low mood, anxiety, paranoia, trouble concentrating, confusion, insomnia, dramatic mood swings, obsessive thoughts, compulsive behaviors, alcohol abuse, substance abuse.
Current level of distress *
If you are in severe distress, please call 911 or go to your nearest emergency department. The national suicide prevention number is 800-273-8255.
no current complaints
severe distress
How did you find out about Dr. Salvatore? *
Please be specific
How long can you wait for an appointment? *
Dr. Salvatore's practice is often closed for new patient appointments. When space does open up, the wait is typically longer than two weeks. Office hours are limited to weekdays between 8 AM and 6 PM.
Are you currently in treatment with a psychotherapist or counselor? *
Are you currently receiving psychotropic medication prescribed by a physician or nurse practitioner? *
What is your availability for the first appointment? *
Office hours are typically from 8 AM-6 PM, Monday through Friday.
What are your thoughts regarding remote psychiatry via video? Please click on all that apply. *
Acknowledgement of above information about payment and insurance
Payment and Insurance ·

Full payment is required by the end of each session. Acceptable forms of payment include personal checks, credit cards, Apple Pay, and cash. · To maximize time spent on clinical matters, patients are encouraged—and in some cases required—to provide credit card information early in treatment. This data will be securely stored using digital encryption technology. Office visits, including missed appointments, will be billed automatically unless otherwise arranged. · Dr. Salvatore is considered an out-of-network provider to all patients. This means he does not have contracts with insurance companies to accept copayments or coinsurance for office visits, and therefore patients are responsible for the full payment of each office visit.  

Most insurance plans offer partial reimbursements for out-of-network office visits. Patients are responsible for determining what level of reimbursement they are entitled to receive under this arrangement. · Shortly after an office visit with Dr. Salvatore. patients will receive a billing statement by mail or email that can be submitted to their insurance companies for reimbursement. This statement will contain all the information necessary for a claim to be processed, including diagnosis (ICD) and encounter (CPT) codes, Dr. Salvatore’s Tax ID number, fee and date of service.
Payment and Insurance *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy