New Patients

New Patient Intake Form

To start the intake process, please fill out the form below.
The Intake Coordinator will get back to you within 2 business days with available appointments.
**We are offiering intakes via TELEHEALTH ONLY at this time***

Demographic Information

* Indicates required field

Name *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Clinical Information

Specific Issue *

Availability *

Insurance Information

Select One *

ID Number *

Policy Holder's Name *

Policy Holder's Date of Birth *

MA Recipient Number *

Provider Services Phone # *

How did you hear about us? *

Comments *

Front of the Insurance Card (optional) *

Max file size: 20MB

Back of the Insurance card (optional) *

Max file size: 20MB

Get me scheduled!

Locations

Eldersburg
5420 Klee Mill
Road
# 4
Eldersburg, MD

Columbia
10440 Shaker Drive
#207
Columbia, MD

Sykesville
7524 Main
Street
#101
Sykesville, MD

Westminster
1812 Baltimore
Blvd
Suite C
Westminster, MD

Telehealth
Cumberland, MD