Community Behavioral Health Intake Questionnaire
Thank you for contacting Community Behavioral Health for your behavioral healthcare needs. We are an outpatient Joint Commission accredited community mental health clinic operating in the Eastern and Western shores of Maryland. We offer therapy, intensive therapy, substance abuse treatment with medical assistance, transcranial magnetic stimulation, psychiatric services including long acting injectable medication, psychiatric rehabilitation program services, and respite care. We aim to serve individuals and communities by challenging them for change.

By answering our intake questions, you will help us get to know you before we meet you. We will be able to provide our specialty team of therapists and psychiatrists with an idea of your history so they can streamline your care.
Email address *
Preferred Treatment Location *
Please indicate if you may prefer these future locations
Easton
Snow Hill
Future Clinics
WHO
The following questions allow us to understand more about the patient's specific needs and eligibility for certain services within our clinics.
Name (first, middle, last) *
Your answer
Date of Birth (MM/DD/YYYY) *
Your answer
Gender *
Social Security Number *
Your answer
For adults, list a form of legal identification (e.g. passport or driver’s license) with numbers
Your answer
Relationship Status *
Sexual Orientation *
Are you a veteran? *
Are you a hurricane victim? *
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