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 CLOSED for Eldersburg, Sykesville & Westminster**

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 *

Columbia Cumberland Frederick Telehealth

Service *

Mental Health Therapy Med Management Speech & Language Therapy

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 *

Preferred Pronouns *

Preferred Name *

Front of the Insurance Card (optional) *

Max file size: 20MB

I certify that *

The patient is NOT waiting for Eldersburg, Sykesville or Westminster

Back of the Insurance card (optional) *

Max file size: 20MB

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
Drive
#207
Columbia, MD

Eldersburg
5420 Klee Mill
Rd
# 4
Eldersburg, MD

Frederick
1 West Church
Street
3rd Floor
Frederick, MD

Sykesville
7524 Main
Street
#101
Sykesville, MD

Westminster
1812 Baltimore
Blvd
Suite C
Westminster, MD

Telehealth
Cumberland, MD