Shelly Khaldi, LMHC, LPC, NBCC

Therapy for Individuals, Couples & Families

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Helpful Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059

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:

Authorization to Disclose Information Form

Note: To download Adobe Acrobat Reader for free, Click here.

Your Name:

Your Phone Number:

Your Email Address:

Your Message:

Please do not submit any Protected Health Information (PHI).

Office hours by Appointment

Tampa, FL
300 S Hyde Park Ave
Tampa, FL 33606

(727) 992-0038

Trinity, FL

2144 Seven Springs Blvd. Unit
#406 Trinity, FL 2144 Seven
Spring Blv.

Shelly Khaldi, LMHC, LPC, NBCC

Therapy for Individuals, Couples & Families

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OUR LOCATION

300 S Hyde Park Ave,
Tampa, FL 33606

(727) 992-0038

2144 Seven Springs Blvd. Unit #406 Trinity, FL 34655