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  • 610 Santa Monica Blvd #218 | Santa Monica, CA 90401
    mmmirell@gmail.com | (310) 383-0216

  • Margie Mirell

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    Client Forms

    If you are new to the working with me, please be sure to fill out the following forms, and bring them to your first session. This will help ease you in and allow as much time as possible to focus on you.

    Client Intake Form

    Information Sheet

    Consent for Treatment

    Treatment Agreement

    If you feel that you would like to collaborate your session with another provider, simply fill out the following form.

    Authorization for Release of Information

    Contact Today


    610 Santa Monica Blvd #218
    Santa Monica, CA 90401

    (310) 383-0216
    mmmirell@gmail.com

    Contact Today

    By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

    Westside Relationships Center
    mmmirell@gmail.com | (310) 383-0216

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