ROBERTA SHAPIRO, M. Ed; LCSW; NBCCH DIPLOMATE,
AMERICAN BOARD OF PSYCHOTHERAPY
4530 Prairie Avenue
Miami Beach, Florida 33140
Tel: (305) 674-8158
Fax: (305) 534-2304
E-MAIL Robertashapiro305@gmail.com


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?

No -> Not applicable

Yes ->

How long ago? Whom did you see?

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.