If you're a new client, please complete the following forms and bring them to your first therapy session. If dually insured, please complete Client Psychotherapy Referral Form for Medicaid Insurance.
Please print and fax to (301) 429-6181 or email to email@example.com.
(If you have additional pertinent information i.e. Medical reports, Discharge Reports etc. please fax/email as well.)
- Client Psychotherapy Referral Form (Medicaid Insurance)
- Client Psychotherapy Referral Form (Non-Medicaid Insurance)
- Notice of Privacy Practices Form
If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
Note: To download Adobe Acrobat Reader for free, click here.