top of page
![](https://static.wixstatic.com/media/bc3ec7bc825c4e6ca746c659189cea83.jpg/v1/fill/w_288,h_162,al_c,q_80,usm_0.66_1.00_0.01,blur_2,enc_auto/bc3ec7bc825c4e6ca746c659189cea83.jpg)
![](https://static.wixstatic.com/media/a69733_031958d0977d4a4c888a9d43fe838b49~mv2.png/v1/crop/x_275,y_0,w_2449,h_438/fill/w_465,h_85,al_c,q_85,usm_0.66_1.00_0.01,enc_auto/a69733_031958d0977d4a4c888a9d43fe838b49~mv2.png)
​
If you're a new client, please complete the following forms and bring them to your first therapy session.
​
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
Note: To download Adobe Acrobat Reader for free, click here.
![](https://static.wixstatic.com/media/a69733_7a86bb8831b94ac39df34bb94cb034ec~mv2.png/v1/fill/w_477,h_74,al_c,q_85,usm_0.66_1.00_0.01,enc_auto/a69733_7a86bb8831b94ac39df34bb94cb034ec~mv2.png)
​
Lake City, FL 32025
email: heartcentered@shaledamirralcsw.com
Dr. Sha'Leda Mirra, PhD, M.Div., MS, LCSW, CAP
(352) 247-2383
![](https://static.wixstatic.com/media/a69733_d8c951c10ec3465d8bd12047385f5b66~mv2_d_3000_2230_s_2.png/v1/fill/w_243,h_181,al_c,q_85,usm_0.66_1.00_0.01,enc_auto/a69733_d8c951c10ec3465d8bd12047385f5b66~mv2_d_3000_2230_s_2.png)
Book Me for your next Mental Wellness Workshop!
bottom of page