Client Intake Form
Thank you for contacting Summit and taking an important step towards your mental health and wellbeing. Answering the following questions will help us to find a clinician for you.  We will get back to you within 48 hours. The information you shared on this form will only be used for treatment and payment purposes.

Please contact our office at 410-329-1200 or email if you are unable to complete the online questionnaire.
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Email *
Name *
Date Of Birth
Phone Number
Preferred Contact method
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I am seeking services for
Anything else we should know before potentially matching you with one of our clinicians?
How did you find out about Summit?
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Preferred Session Type
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