Lori Shapiro Forms

I look forward to meeting with you very soon. Please complete the forms and bring them to the first session or take the first few minutes of your session to fill them out after I greet you in the waiting area.

NOTE ABOUT PAYMENT: Payment is expected at each session. Checks or cash are preferred. A 4% discount is given for payment by cash, checks, or ACH direct debit. Please make checks payable to “Keith Miller Counseling, LLC.” We also accept Visa, MasterCard, and Discover and American Express (see credit card form below).

The following three forms are REQUIRED for meeting with Lori Shapiro:

Shapiro Client Clinician Agreement Form

Client Data and Consent for Care Form

Physician release of information

 

The following forms are OPTIONAL and used only when needed

Visa MasterCard Discover AmEx Form (full fees apply to credit card users)

ACH Forms

Consent for Release of Information