SE HABLA ESPANOL
Online- www.tamaramonell.com www.liveperson.com/tamara-a-monell
Phone- 1 (888) My Ether (693-8437) ext. 02337184 *Arrange calls by email @ info@tamaramonell.com
Office Phone-(786) 287-0837 Please leave detailed message with contact info & service request.
South Miami Location- Self-Enrichment Center 7600 Red Road #309 South Miami 33143 Office Ph:# 786-287-0837 Email: info@tamaramonell.com
Email- info@tamaramonell.com * Feel Free to copy & paste the following service request form when emailing me.
Service Request Form Name: _______________ ID#: ___________
(Last) (First) (Middle Initial)
Birth Date: ______ /______ /______ Age: ________ Gender: □Male □Female □Other (specify_____________)
Marital Status: □Never Married □Partnered □Married □Separated □Divorced □Widowed
Ethnicity: □African/American □Chicano/Mexican-American/Puerto Rican □Chinese/Chinese American
□East Indian/Pakistani □Filipino □Japanese/Japanese American □Korean/Korean-American
□Latino/Latino American/Hispanic □Middle Eastern □Native American/Alaskan Native
□Polynesian/Micronesian □Vietnamese □White/Caucasian □Other (specify________________)
Local Address:
(Street and Number) (City) (State) (Zip)
Home Phone: ( ) – May we leave a msg? □Yes □No
Cell or
Other Phone: ( ) – May we leave a msg? □Yes □No
E-mail: May we email you? □Yes □No
*Please be aware that email might not be confidential.
Emergency Contact Name: Relationship:
Address: Phone:
Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere? □Yes □No
Have you had previous psychological □No □Yes, off campus
counseling? □Yes, at UCSD (Previous P&CS counselor’s name_____________________)
Are you currently taking prescribed psychiatric medication (antidepressants or others)? □Yes □No
If no, have you been previously prescribed psychiatric medication? □Yes □No
Why are you requesting my services and for how long?
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