Appointment Request Form

Appointment Request Form

Getting started with Doro Mind
This form is for requesting an appointment with a Doro Mind care team member. Our goal is to connect you with the best care possible as quickly as we can. To facilitate that we will use this from to schedule your first appointment with an expert nurse practitioner directly. Your appointment can be with any member of the family that is seeking support.

If you have additional questions or if you would prefer to speak with a staff member about Doro Mind before scheduling an appointment you can schedule a welcome call using this link or you can text the word "hello" to (877) 375-3371.

Doro Mind is not a crisis service. If you are in need of immediate assistance for a mental health crisis please dial 988 to speak with a trained counselor immediately.
What is your role?*

Individual seeking care for myselfFamily caregiverClinical providerOther
Your Full Name*

First NameLast Name
Your Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
Would you like to join the Doro Mind mailing list to learn about updates to our services and events?

YesNo
Consent to use SMS text messaging:

Yes, I approve receiving text messages.No, I do not wish to receive text messages. Please use email or phone call.
How did you hear about Doro Mind?

Information for person seeking services

Please provide the following personal information for the individual you are seeking care for.
Name of the person you are seeking services for:

First NameLast Name
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to provide additional contact information for the individual you are seeking services for?*

Yes, please contact them directlyNo, please use my contact information

Additional contact information

This contact information will be used to share appointment information.
Email of person seeking services:
example@example.com
Phone Number of person seeking services:
Please enter a valid phone number.

Additional personal information
What mental health condition are you seeking support for?*
How long have you been observing symptoms?
Date of birth for person seeking services:

MonthDayYear
Date
Is there any additional context you would like our care team to be aware of?
Are you or your loved one a current patient of Dr. Laitman and/or Dr. Mandel?*

YesNo
Doro Mind may have income based grants available to reduce costs. Please complete the following information in order to determine your eligibility.
Family annual income:
Number of people in the household:
Health Plan Type*
Health Plan*
If other health plan, please describe:

Information for person seeking services