Online- www.tamaramonell.com www.liveperson.com/tamara-a-monell

Phone- 1 (888) My Ether (693-8437) Arrange calls by email  ext. 02337184 

Voicemail-(786) 287-0837 Please leave detailed message with contact info & service request.

Email- tamonell4@aol.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?­­­