ROBERTA SHAPIRO, M. Ed; LCSW; NBCCH DIPLOMATE, AMERICAN BOARD OF PSYCHOTHERAPY 4530 Prairie Avenue Miami Beach, Florida 3310 Tel: (305) 674-8158 Fax: (305) 534-2304 E-MAIL rshap33@earthlink.net
Name:
Address:
City:
State:
Zip Code:
Date of Birth
Telephone (home):
Telephone (Work):
Telephone (Cellular):
Email Address:
Marital Status:
Children:
Are you currently being treated for any medical condition?
Have you received psychological treatment in the past?
Yes ->
Who referred you?
What are your goals for therapy?
SERVICES ARE PAYABLE WHEN RENDERED. PLEASE ACKNOWLEDGE THAT YOU ARE RESPONSIBLE FOR SUCH PAYMENTS BY PLACING A CHECKMARK IN THE "I ACCEPT" BOX BELOW.
Print Name:
I accept:
Please be advised there is a 24 hour cancellation policy.
Thank you for taking the time to fill out this form.