Client Information Form

Client Information Form

Michael Romanelli, LCSW-R
100 N.Village Ave. Suite 24
Rockville Centre, NY 11570
P. 516-594-4408
License: R069920 NPI: 1326118621

Treating individuals and couples for a variety of concerns. I commonly work with insurances such and NYSHIP and Aetna on an out of network basis. Please complete the information form below and I will reply as soon as I am able to.
Full Name*
Date of Birth*

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Address*

Street Address

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Phone Number*
E-mail*
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Reason for visit*
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