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If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911 or go to your closest emergency room.
I understand completing this form does not establish a doctor-patient relationship with Dr. Capuco, nor does it guarantee an appointment.
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Dr. Capuco does not currently participate as an in-network provider for any insurance plans. I understand that I am responsible for payment in full at the time of service.
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No, this will not work for me.
What are the main issues you are struggling with?
Anxiety
Depression
Attentional Difficulties
Bipolar Disorder
OCD
Trauma
Psychosis
Cognitive Decline
Anger
Substance Abuse
Sleep Issues
Relationship Issues
Difficult Life Transitions/Grief
Technology Addiction (social media, video games, etc)
Other (explain below)
Please check all of the following that are applicable
In therapy now
In therapy in the past
On psychiatric medication currently
On psychiatric medication in the past
Hospitalizations for psychiatric reasons in the past
Attempted suicide in the past
None of the above
What type of being care is sought currently?
Medication Mangement
Therapy
Medication + Therapy
Consultation/Second Opinion
Not Sure
If you'd like, please provide more information about what you are hoping to get help with
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