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) Alternate Phone # 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 PhoneThis field is for validation purposes and should be left unchanged.