Website Contact Form
We are so glad that you want to connect and get more information about our services. Whether you just have some questions or would like to get scheduled with one of our clinicians this form will allow us to help you best.
Please fill out to your best ability and we will be in touch shortly. If you do not hear back from us within 24-48 business hours please reach back out to us as we may not have received your request. Please remember you can always contact us at 410-841-9647.
Name of Individual seeking Counseling (First and Last)?
If different from above, please tell us your name (First and Last)?
Preferred way to contact you (please note that email may not be a secure means)
Phone (OK to leave a Voice message)
Phone (Please do not leave a Voice Message)
Good Contact number
What is the best time to contact you between 8am and 4pm?
How can we assist you?
I would like more information
I want to schedule an appointment
I'd prefer to talk over the phone about what I need.
If you are looking to schedule, please tell us your time preferences:
Day time hours (8-3pm)
Afternoon hours (3-5pm)
Evening hours (5-9pm)
Which counselor(s) would you prefer?
Ashley (4yo-35 yo)
Kristine (5 +Tween & 18+)-Currently Full
If the counselor does not have availability, would you like to be added to the waitlist?
Service being requested
Young Child (4-8)
Young Adult (18-26)
Please check all that may apply :
Anxiety | Depression
Pregnancy & Beyond
Trauma | EMDR
Dance Movement Therapy (Currently on hold)
If you can provide a little information about why you are seeking counseling, this will help us determine the best match for you:
If you're interested in scheduling, please indicate below which insurance company you currently have. (Please note that our clinicians may not be in-network with your particular insurance plan. If you plan to use out-of-network insurance benefits, we will be happy to discuss your options with you.)
Blue Cross Blue Shield HMO
Blue Cross Blue Shield PPO
Blue Cross Blue Shield Federal
John Hopkins EHP
John Hopkins USHP
United HealthCare (non-Medicaid)-Not in network
Medicaid (not in-network)
Medicare (not in-network)
Please tell us how you heard about us
Psychology Today|Therapy Den
Heard about you through a friend
Google Ad |Facebook Ad
Would you like to be added to our Mailing list to receive updates?
Never submit passwords through Google Forms.
This form was created inside of Carlada Razmus LCPC.