1. How did you hear about Dr. Shalts?

Was referred by one of his patients.
Was referred by my health provider.
Found him on the internet.
Read one of his books.
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Name of Referring Provider *

2. Are you looking for help for your child? *

Yes

3. Are you currently taking psychotropic medications? *

Yes

Please list your current psychotropic medications.

4. Are you looking for a provider to help you to decrease or discontinue your current psychotropic medications? *

Yes

5. Are you currently taking benzodiazepines (medications like Xanax, Klonopin, Ativan, Valium)? *

Yes

6. Are you actively abusing alcohol? *

Yes

How many drinks do you have on a typical day? *

7. Are you actively using street drugs? *

Yes

8. Are you on a Methadone program? *

Yes

9. Are you prescribed Suboxone? *

Yes

10. Have you been diagnosed with Schizophrenia or Schizoaffective Disorder? *

Yes

11. Have you been diagnosed with Bipolar I Disorder? *

Yes

12. Have you ever felt suicidal? *

Yes

What service are you interested in? *

Conventional psychopharmacology

Functional Psychiatry and nutrition

Quantitative EEG / neurofeedback

Homeopathy

What would you like us to know before your appointment? *

First Name *

Last Name *

Mobile Phone *

Email *

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I consent to receive non-marketing text messages from Dr. Shalts about my appointment reminders and support requests. Message & data rates may apply.

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