Referral Form
Referral to request services

(Please note that someone from our office will contact you within 24 - 48 business hours to schedule).
Email address *
Date *
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What state does the client reside in? (Currently Changing Tides Counseling & Behavioral Health, LLC provides services to residents of Maryland, District of Columbia, & Virginia). *
Client First Name *
Client Last Name *
Custodian/Guardian Name (if applicable)
Primary Language *
Client Date of Birth *
MM
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DD
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Client Gender *
Client Race *
Physical Address *
Zip Code *
Home Number *
Cell Number *
Is it okay to leave a voicemail on this number? *
Is it okay to send a text message to this number? *
Primary Care Provider
Primary Care Provider Telephone #
Services Paid By *
Required
Do you have Medicaid coverage? *
Insurance Provider
Insurance ID#
Availability *
Reason For Referral *
Comments
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