Baltimore Therapy Center

Baltimore Therapy Center - Intake Form

First Name *

Last Name *

Sex *

Age *

Date of Birth *

YYYY

Street Address: *

City, State, Zip *

Home Phone

Okay to leave message on home phone?

Yes

Clear selection

Mobile Phone *

Okay to leave message on mobile phone? *

Yes

Work Phone

Okay to leave message on work phone?

Yes

Clear selection

E-mail Address

How did you hear about the Baltimore Therapy Center?

Google search results

Psychology Today

Facebook

Thumbtack.com

Heard about it from my partner

Referred by a friend

Referred by another professional

Other:

Clear selection

Please read the Terms of Consent to Treatment at https://www.baltimoretherapycenter.com/forms/consent.pdf. *

I have read the Baltimore Therapy Center’s Consent to Treatment. I understand the terms and agree to them. I agree to treatment with the Baltimore Therapy Center, LLC.

Required

Please read the Notice of Privacy Practices at www.baltimoretherapycenter.com/forms/NPP.pdf. *

I have read the Baltimore Therapy Center’s Notice of Privacy Practices. I understand the terms and agree to them.

Required

I request that the Baltimore Therapy Center use the following electronic communication methods to communicate with me:

Regarding the use of electronic communication methods: • I understand that e-mails sent to me are encrypted, but e-mails I send are not. • I understand that text (SMS) messages sent in either direction are not encrypted. • I understand the risks of using unencrypted methods as described in the Consent to Treatment. • I understand that I am not required to sign this agreement in order to receive treatment and that I have the right to terminate this authorization at any time.

E-mail

Text messaging

I DO NOT wish to use these communication methods. I understand that I have the option of avoiding electronic communications entirely, or of downloading the Signal messaging app for secure and encrypted communications with the Baltimore Therapy Center.

CANCELLATION POLICY: Please note that sessions must be cancelled no less than 24 hours in advance. Sessions cancelled or rescheduled within 24 hours and no-shows will be billed the full session fee. The only exception to this rule is a documented medical emergency. *

I accept the terms of this cancellation policy.

Required

Will you be receiving telemental health services (online sessions)? *

Yes

Maybe

Electronic signature: Please type your name below. *

Please check below to indicate your agreement that your typed name above will act as your electronic signature. *

If you do not wish to sign electronically, you may print out the required documents at https://www.baltimoretherapycenter.com/policies-forms

I agree

Required

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