New Client Inquiry Form

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New Client Inquiry Form

Thank you for your interest in our services, please take a moment to provide us with some initial information that will help us determine if we may be a good fit for your family.

Name of person filling out form (First, Last Name):

Relationship to potential client:

Self

Parent

Guardian

Treatment Provider

Clear selection

Phone number of person completing form:

Email address for person completing form:

Name of Potential Client

Age of Potential Client (number only)

What are the concerns for which you are seeking help?

Are you seeking a specific type of treatment?

Dialectical Behavior Therapy

Behavioral Parent Training

Cognitive Behavioral Therapy

Exposure and Response Prevention

Prolonged Exposure Therapy

Acceptance and Commitment Therapy

I am not sure

Other

Clear selection

Are you seeking treatment for:

Anxiety

Anger

Depression

Social difficulties

School avoidance

Behaviors identified as "high-risk"

Substance abuse

Suicidal ideation

Self injurious behavior

Suicide attempt

Other

If any selected, please explain:

State of residence

Maryland

Virginia

District of Columbia

Clear selection

Are you seeking in-person therapy or tele-health services?
Note: Our groups are ALL in person at this point.

In-person services only

Tele-health (HIPAA compliant zoom is only available if the clinician is licensed in the state you are physically located in at the time of your appointment)

Either

Clear selection

Were you referred to a specific therapist at our practice? If so, who were you referred to?

Does the client have any specific preferences when it comes to clinician (e.g., gender, specialty, hours of availability, therapy style)?

Are there any scheduling constraints you are hoping to work around (school, sports, extra curricular activities, etc.)?

Is the client willing to come in for services if the appointment time conflicts with one of these activities? For example, would the client be able to come in during school hours if that was the only available time?

Yes

Clear selection

How did you hear about us?

Submit

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