Mitchell E. Spero, Psy.D. / Director

Licensed Psychologist / FL# PY004098
Certified & Court Appointed Family Mediator:
Supreme Court of Florida

Sawgrass Medical Center
12651 West Sunrise Blvd, Suite 101
Sunrise, FL  33323-0906

Phone (954) 587-7520
Phone (954) 349-2777

fax (954) 587-7527
fax (954) 349-3440

Specializing in the Treatment of Emotional and Behavioral Problems of Children and Adolescents / Psychotherapy & Psychological Evaluations of Children, Adolescents & Adults.

  • Divorce & Stepfamily Adjustment
  • Custody Evaluations / Expert Testimony
  • Single Parenting Issues
  • Marriage and Family Therapy
  • Drug & Alcohol Abuse Counseling
  • Child & Adolescent Oppositional Behaviors (School and Home)
  • Attention-Deficit / Hyperactivity Disorder Evaluation & Treatment
  • Treatment of Depression and Anxiety
  • Free Initial Telephone Consultation

Helping Children & Families Since 1983 in Broward County.
Problem solving for all ages…

Revised 01/15/21

© 2021 Child & Family Psychologists
All Rights Reserved
Reproduction Expressly Prohibited

1Notice of Privacy Practices Patient Acknowledgment
2Child/Adolescent/Young Adult Intake Form
3Family Information, Father & Mother
4Family Information, Siblings
6Family Relationships
7Family Background Information
8School History and Adjustment
9Medical History
10For Therapist Use Only
11Initial Consent for Treatment
12Consent for Treatment Financial Agreement
13The office Cancellation / No-Show Policy
14Patient Financial Responsibility Agreement
15Patient Information Release Authorization 1
16Patient Information Release Authorization 2
17Patient Information Release Authorization 3
18Mental Status Examination / M.S.E.
19Telehealth Disclosure
20Upload Docs
  • Child & Family Psychologists
    12651 W. Sunrise Blvd. Suite 101
    Sunrise, Florida 33323-0906
    (954) 587-7520 / (954) 349-2777

    Notice of Privacy Practices
    Patient Acknowledgment

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  • I have received this practice's Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practice's legal duties with respect to my protected health information. The Notice includes:

    • A statement that this practice is required by law to maintain the privacy of protected health information.
    • A statement that this practice is required to abide by the terms of the notice currently in effect.
    • Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment, and health care operations.
    • A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my written consent or authorization.
    • A description of uses and disclosures that are materially limited by law.
    • A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
    • My individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to:
      • The right to complain to the Privacy Officer of this Practice and to the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
      • The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
      • The right to receive confidential communications of protected health information.
      • The right to amend protected health information.
      • The right to receive an accounting of disclosures of protected health information.
      • The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.

    This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice's current Notice of Privacy Practices on request.

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