Frequently Asked Questions

FAQ's

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We can offer our services to Hindi, Punjabi, Urdu, speaking patients.

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Patient Information

Patient First Name

Patient Middle Initial

Patient Last Name

Guardian / Healthcare Proxy

Gender Identity

Marital Status

Birth Day

Birth Month

Birth Year

Social Security Number

Primary Phone

Cell Phone

Email Address

Enter Email Again

Address

City

State

Zip Code

Emergency Contact Full Name

Emergency Contact Phone

Emergency Contact's Relationship

Occupation

Position

Employment Type

Employer Name

Work Phone

Work Address

City

State

Zip Code

Insurance Information

Do You Have Primary Insurance?

Yes No

Primary Insurance Holder

First Name of Primary Insured

Last Name of Primary Insured

Primary Insurance ID #

Primary Insurance Name

Insurance Group Name

Insurance Group Number

Birthdate of Primary Insured

Upload Insurance Card Front Side

Upload Insurance Card Back Side

Do You Have Secondary Insurance?

Yes No

Secondary Insurance Holder

First Name of Secondary Insured

Last Name of Secondary Insured

Secondary Insurance ID #

Secondary Insurance Name

Insurance Group Name

Insurance Group Number

Birthdate of Secondary Insured

Upload Insurance Card Front Side

Upload Insurance Card Back Side

Identity Verification / Driving License

Upload Front Side of Your Driving License

Upload Back Side of Your Driving License

Psychiatric History Information

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

Yes No

Previous Therapist / Practitioner Name:

Are you currently taking any prescription medication?

Yes No

If yes, please list:

Have you ever been prescribed psychiatric medication?

Yes No

If yes, please list:

Please list any specific health problems you are currently experiencing:

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise do you participate in?

Please list any difficulties you experience with your appetite or eating problems:

Are you currently experiencing overwhelming sadness, grief or depression?

Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panics attacks or have any phobias?

Yes No

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain?

Yes No

If yes, please describe:

Do you drink alcohol more than once a week?

Yes No

Are you currently in a romantic relationship?

Yes No

If yes, for how long?

What significant life changes or stressful events have you experienced recently?

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

You may list any additional info about family history of trauma or adverse childhood experiences:

Additional Information

Are your currently employed?

Yes No

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious?

Yes No

If yes, describe your faith or belief:

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in sessions with the provider at Kapoor Cares LLC - Circle one of the options and may add more at the space below.

Write more info if any

Primary Care Doctor

Primary Care Doctor's Name

Primary Care Doctor's Phone

Primary Care Doctor's Fax

Primary Care Doctor's Address

City

State

Zip Code

Neurologist

Neurologist's Name

Neurologist's Phone

Neurologist's Fax

Neurologist's Address

City

State

Zip Code

Pharmacy Details

Preferred Pharmacy Name

Pharmacy Phone Number

Pharmacy Address

City

State

Zip Code

Consent to Treatment

Check Below

I do hereby agree to Kapoor Cares LLC Office Policies & Treatment Agreement. Kapoor Cares LLC will send delinquent account /UNPAID BALANCE over 90 days to a debt collection agency, and the patient will be responsible for payment of collection, attorney's fees, and court costs associated with the recovery of the monies due on the account.

Patient First Name

Patient Last Name

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Please Note: If this is an emergency please call 911