UME Farm Stress Therapy Intake Form
Please complete the form below. A member of the UME Farm Stress team will reach out to confirm your request and assist with linking you to an available behavioral health provider. We will also work with you to secure technology / transportation assistance if needed to attend your appointment. Please email us at mdfrsan@umd.edu with any questions.
Sign in to Google to save your progress. Learn more
Client's Full Name *
Preferred Name (optional)
Which of the following are you? *
Address (Street, City, State, Zip) *
Phone Number *
Can we leave a voicemail at this number? *
Email
Date of Birth *
MM
/
DD
/
YYYY
Age *
Race *
Marital Status *
Gender *
Are you able to do your sessions online or in person? (Note: we will be providing resources to assist clients with online sessions) *
Please describe why you are seeking therapy services. *
Please list some times and dates that you are available for a team member to contact you with further steps. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy