In an effort to serve you better, this form requests background information, including demographics, reason for seeking counseling services at this time, and past efforts to address your concerns.
Similar to the Personal Information Form for Adults, this form requests background information on the child or adolescent coming for counseling.
This document contains important information about Sarah Shapiro’s professional services and business practices. When you sign this document, it will represent an agreement between you and Sarah Shapiro.
In accordance with federal law, this notice describes how medical information about you may be used and disclosed and how you can get access to that information. This notice is intended for your records only and does not need to be returned to Sarah Shapiro.
Signing this form acknowledges that you have received and have been given an opportunity to read a copy of this office’s Notice of Privacy Practices.
9199 Reisterstown Road
Owings Mills, MD 21117
Sarah Shapiro, LCSW-C
Copyright © Sarah Shapiro, LCSW-C. All rights reserved.
P.O Box 517
Stevenson, MD 21153
Specializing in short-term counseling to address life's challenges and transitions
LICENSED SOCIAL WORKER
Thank you for your interest in short-term counseling services. Should you choose to schedule an appointment, please download, print, complete, and return the forms to the right to Sarah Shapiro, preferably via email prior to your first appointment. You may also bring these forms with you to your first appointment.