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 not taking new Medicaid Patients at this time**
**The waiting list is open for Frederick, Columbia (daytime) and Telehealth ONLY!**

Please Read FAQ's before filling out the form below

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 *

Location/Service *

Frederick Telehealth Columbia

Availability *

Service *

Mental Health Therapy Med Management Speech & Language Therapy

Insurance Information

Select One *

ID Number *

Policy Holder's Name *

Policy Holder's Date of Birth *

Provider Services Phone # *

Front of the Insurance Card *

Max file size: 20MB

How did you hear about us? *

Back of the Insurance card *

Max file size: 20MB

Optional Questions

Preferred Name *

Preferred Pronouns *

Gender Identity *

Race/Ethnicity *

Get me scheduled!

Please check your Junk Box if you do not receive a reply in 2 business days. If you still have not received a response, email Intake@AnchorCounselingCenters.com.

Locations

Columbia
10440 Shaker Dr
#207
Columbia, MD

Cumberland
Virtual Only

Eldersburg
1645 Liberty Rd
#104
Eldersburg, MD

Frederick
1 West Church St
3rd Floor
Frederick, MD

Sykesville
7524 Main St
#101
Sykesville, MD

Westminster
Virtual Only

Colorado
Main Street
Frisco, CO

Phone
443-328-4946
Fax
410-875-7687

Careers