Divine Counseling Referral Form
This form is to be completed by individuals seeking therapeutic services with Divine Counseling.  Please be mindful that this is not an intake form, and further information will be collected once you are enrolled in services.  
Upon completing this form, please expect to be contacted by one of our Program Administrators (PA's) within 48 hours.  Once connected with a PA, you will be sent a link to complete your patient portal, including our client handbook and consent forms.  
Please be patient as this process takes time and our PA's work hard.  Once all forms are completed and insurance is verified, our typical enrollment time for clients to meet with a clinician is 7 business days.  
For any questions or concerns, please contact us at 443-955-2662
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Email *
Client's Name *
Client DOB *
MM
/
DD
/
YYYY
Address *
Clients Sex *
Clients' Preferred Pronouns *
Parent/Guardian name (if applicable) *
Relationship to client *
Phone number *
Email *
Divine Counseling currently provides services in Maryland, Virginia, and DC.  Where are you seeking services? *
What type of insurance will you be using? *
Required
Why are you seeking services with Divine Counseling? (Presenting Problem) *
What do you hope to gain from therapy? (Treatment Goals) *
How difficult are your concerns to deal with? *
Not difficult at all
Extremely difficult
Are you currently taking any prescribed medications?  If yes, please list them  *
Current/Preferred Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8am-10am
10am-12pm
12pm-2pm
2pm-4pm
4pm-6pm
6pm-8pm
Do you have any preferences regarding your treatment?  If so, please specify. *
How did you find out about us? *
Required
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