Susan B. Jacobson, L.M.H.C., P. A.

 Office Visits Or Telephone Therapy, Boca Raton Counselor, Palm Beach Florida

 A South Florida Therapist for Marital, Divorce, Family and Child Counseling.

All my clients receive the highest quality of care and empathy. I believe that honesty and gentleness can be very powerful.

Client Intake Form:

E-mail Address: *
Full Legal Name / Childs Name: *
Date: Select Date
Current Address
City:
State:
Zip:
Home Phone:
Cell / Mobile Phone:
Business / Work Phone:
Fax Number:
Client Information:Male
Female
Marital Status:Single
Married
Divorced
Widowed
Children
Date Of Birth:
Last Four Numbers of Your SSN:
Highest Education Completed:High School
Bachelors
Masters
Religious Affiliation:
Briefly Describe Why You Are Seeking Help At This Time:
Have You Ever Seen A Mental Health Professional Before:Yes
No
If Yes, When
If Yes, With Whom
Presenting Problems:Yes
No
If Yes, Please Tell Us What You Are Being Treated For:
Your Physicians Name:
Your Physicians Telephone:
In Case Of An Emergency, Whom Should We Notify:
Emergency Telephone:
When Is The Best Time To Contact You?
Morning
Afternoon
Evening
What Is The Best Way To Contact You?
Home Phone:
Mobile Phone:
Business Phone:
Fax:
Email:
Whom May We Thank For Referring You To Our Practice:Yellow Pages
School Counselors
Brochures
Other
Message:
* Required
 


 About My Profession

* Home Page
 * About Me
 * Contact My Office
 * About My Profession
 * My Published Works
 * Professionals I Work With
 * Client Intake Form
 * A Video Of My Profession
 * Sitemap

Services Offered

* My Counseling Service
* Crisis Counseling
* Office Visits
* A Phone Therapy Session
* My House Call Service
* Safe, Supervised Visitation Service
* My Resume & Certifications
* Parental Alienation Syndrome (PAS)

Published Books & ArticlesPsychotherapist In FL

In addition to writing books, I have published many articles. Read More...

 

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© Copyright 2011 Susan B. Jacobson, L.M.H.C., P.A. FLMH 0003657 All Rights Reserved