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Schedule an Appointment
Upon submitting this form, we will contact you immediately if possible, or within 24 business hours.
Schedule an Appointment
Full Name
(Required)
DOB:
(Required)
MM slash DD slash YYYY
Address
(Required)
City State Zip
(Required)
Mobile Phone #
(Required)
Email
(Required)
Preferred Contact
(Required)
Phone
Email
What brings you to therapy?
(Required)
Therapy Technique Requested
(Required)
Anger Management
Cognitive Behavior Therapy (CBT)
Couples Therapy
EMDR
Exposure and ritual prevention (ExRP) therapy
Faith-Based Counseling
Medication Management
Play Therapy
Testing and Evaluation
Mediation Counseling
Other
Desired Therapist Name
Desired Appointment Time
(Required)
Weekday Morning (8-12)
Weekday Early Afternoon (12-3)
Weekday Late Afternoon (3-6)
Weekday Evening (6-9)
Weekend
What insurance do you have?
(Required)
No Insurance, I will pay out-of-pocket
CareFirst (Accepted by All Therapist)
Blue Cross Blue Shield (Accepted by All Therapist)
Cigna (Accepted by All Therapist)
Cigna EAP (Accepted by All Therapist)
Johns Hopkins Healthcare -EHP/PP w/ Cigna Logo (Accepted by Most Therapist)
Johns Hopkins -EHP/PP (Accepted by Some Therapist)
Maryland Medicaid (Accepted by Some Therapist)
United Health (Accepted by Some Therapist)
Tricare (Accepted by Some Therapist)
Medicare (Accepted by Some Therapist)
My insurance is not listed. I will pay and request reimbursement from my insurance
In-person/Virtual
(Required)
In-person
Telehealth
Soonest Appointment (In-Office or Telehealth)
Referral Source
(Required)
Another therapist
Doctor
Friend/Family member
Google
Insurance website
PsychologyToday
Social media
Word of mouth
Other
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