Request an Appointment

Due to the licensing requirements for professional counselors and social workers, we are only able, by law, to meet with clients who are Maryland residents. Please confirm the following: *

I/the person I am seeking therapy for am/is physically located and have/has a mailing address in the state of Maryland, or am/is in the process of relocating to Maryland.

What kind of service(s) are you seeking? *

Please check all that apply

Individual therapy for myself

Individual therapy for my child

Individual therapy for someone else

Couples therapy

Family therapy

Something else

Your Name: *

First Name

Last Name

The birthdate of the person you are seeking therapy for is: *

*Note: If you are seeking couples or family therapy, please put your own birthdate

MM

DD

YYYY

Are any of the following issues bringing you to therapy? *

Please check all that apply

Adjustment/Life Transition Issues

Anxiety

Attention/Focus Issues

Relational Conflict

Family Issues (Ongoing)

Individual or Family Crisis (Acute)

Mood Disorder

Neurodivergence (ADHD, Autism, Learning/Processing Disorders)

Perinatal

School-Based Behavioral Issues

Substance Use

Trauma

Something Else (please describe below)

Please check any preferences that apply:

Female Therapist

Male Therapist

Non-Binary Therapist

LGBTQ+ Affirming Therapist

Gender Affirming Therapist

Specific Therapeutic Approach (please describe below)

Something Else (please describe below)

Please check all the times you would be potentially available for an appointment:

Mornings (before 12pm)

Afternoons (12pm-4pm)

Evenings (later than 4pm)

Weekends

Phone *

(###)

###

####

If we need anything, would you prefer to be contacted by: *

Phone

Email

No preference