Lori M Shula, MA LMHC

Individual, Relationship, Marital and Family Therapy
825 E Cowboy Way Suite # 108
Labelle, FL 33935

If you would like to download a PDF version of the ‘Client Intake Form’, click the button.

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FAX (863) 302-5109

Office Policy


I appreciate you choosing this office for your mental health needs. It is my desire to help you identify and accomplish your goals. However, please keep in mind that this is NOT an emergency mental health service – should you ever require emergency assistance, be sure to call SalusCare at (239) 275-3222 or your prescribing physician. The following information is intended to familiarize you with office policies. If you have any further questions, please fell free to discuss them with me.  

Fee Structure

My fee is $125.00 for each session. Many insurance plans cover mental health counseling. If you have insurance, I will assist you in processing your claim; however, the final responsibility for payment is your. You are responsible for securing any necessary pre-authorization from your insurance carrier prior to the initial date of service as well as remitting any co-pays due at the time of your session.

Time Frame

The length of each session is approximately 45-50 minutes. Should you be late for a session, you will be seen for the remainder of your scheduled session. Since another person is usually scheduled for the next hour, it is not possible to extend to or beyond the next session.

The Therapy Process

I view the therapy process as a process in which a person interacts with a trained, licensed professional in an attempt to bring about positive change. Since most life problems develop over time, it usually takes time to find relief.

Missed Appointments

Cancellations need to be made at least 24 hours in advance. Cancellations made less than 24 hours in advance will be charge the full fee. Messages or text can be left on at any time at (239) 292-4458 or my email at [email protected]

Your Name

If under 18/Parents Names



Work Status

Insurance Information

Other Information

List of Members of your family/others in your home

Notice of Privacy Practices - Brief Version



Commitment to your privacy


This practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care.  I am required by law to keep your information private.  These laws are complicated, but I must give you this important information.  This pamphlet is a shorter version of the full, legally required NPP and you may have a copy of this to read and refer to it for more information.  However, I  can’t cover all possible situations, so please talk to me (see the end of this pamphlet) about any questions or problems.


I  will use the information about your health  received from you or from others mainly to provide you with treatment, to arrange payment for our services, and for some other business activities which are called, in the law, health care operations.  After you have read this NPP I  will ask you to sign a Consent Form to let us use and share your information.  If you do not consent and sign this form we cannot treat you.


If you or I  want to use or disclose (send, share, release) your information for any other purpose, we will discuss this and ask you to sign an Authorization form to allow this.


Of course I will keep your health information private but there are some times when the laws require us to use or share it., For example:


  1. When there is a serious threat to your health and safety or the health and safety of another individual or the public.  We will only share information with a person or organization that is able to help prevent or reduce the threat.


  1. Some lawsuits and legal or court proceedings.



  1. If a law enforcement official requires to do so.
  2. For Workers Compensation and similar benefit programs.


Your rights regarding your health information:


  1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place which is more private for you.  For example, you can request a home call rather than a work call to  schedule or cancel an appointment.  We will try our best to do as you ask.   


  1. You have the right to ask me to limit what I tell people involved in your care or the

 payment for your care, such as family members and friends.


  1. You have the right to look at the health information I have about you such as your client and billing records.  You can even get a copy of these records but I may charge you.  Contact me to arrange how to see your records.  


  1. If you believe the information in your record is incorrect or missing important information, you can ask me to make some changes (called amending) to your health information.  You have to make this request in writing and send it to me including the reasons you want to make the changes.


  1. You have the right to a copy of this Notice.  If we change this Notice of  Privacy Practice, we will post the new version in our waiting area and you can always get a copy from me.


  1. You have the right to file a complaint if you believe your privacy rights have been violated.  You can file a complaint with me as well as with the Secretary of the Department of Health and Human Services.,   All complaints must be in writing.  Filing a complaint will not change the health care I provide to you in any way.  


If you have any questions regarding this Notice of Health Information Privacy Practices, please contact me at 239-292-4458. You may also have other rights which are granted to you by the laws of our state and these may be the same or different from the rights described above.  I will be happy to discuss these situations with you now or as they may arise.  




I understand that Lori M. Shula, LLC may share my health information for treatment, billing and healthcare services.  I have reviewed a copy of the office’s Notice of Privacy Practices that describes how my health information is used and shared.  I understand Lori M. Shula LLC  has the right to change this notice at any time.  I may obtain a current copy by contacting Lori M. Shula, LLC  at 239-292-4458.


Let's Talk

Lori M Shula, MA LMHC

Phone – (239) 292-4458

Fax – (863) 302-5109