Baltimore Therapy Center - Intake Form
First Name *
Last Name *
Sex *
Age *
Date of Birth *
Street Address: *
City, State, Zip *
Home Phone
Okay to leave message on home phone?
Clear selection
Mobile Phone *
Okay to leave message on mobile phone? *
Work Phone
Okay to leave message on work phone?
Clear selection
E-mail Address
How did you hear about the Baltimore Therapy Center?
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Please read the Terms of Consent to Treatment at *
Please read the Notice of Privacy Practices at *
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.
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. *
Will you be receiving telemental health services (online sessions)? *
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
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