Let’s Work Together

1. Name of Client *

First Name

Last Name

2. Date of Birth of Client *

MM

DD

YYYY

3. Name of Parent/Guardian (for minor clients)

First Name

Last Name

5. Phone (for adult clients or guardian of minor) *

(###)

###

####

6. What service(s) are you interested in? *

Individual Therapy

Family or Couples Counseling

Art Therapy

7. What location(s) do you prefer? *

Bel Air Office (in-person)

Towson Office (in-person)

Telehealth (virtual)

8. Is there a specific therapist you would like to work with if available? *

You may select multiple options.

First Available

Lacey Davis

Chelsea Ruggiero

Kristen McDermott

Caitlin Furman

Colleen McCormick

Julia Cover

Jessica Placek

Alexandra Jackson

Leanda Welker

Amanda Lowman

Katie Maniscarco