Client's First Name (If parent requesting services for child, use child's name)
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Client's Last Name
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Phone
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Email
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What's the Best Way to Contact You?
Phone
Email
Text Message
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Whom Are You Seeking Counseling For
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Self
Couples
Child
Family
Parent/Guardian
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Client's Date of Birth (If parent requesting services for child, use child's DOB)
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How would you like to receive services?
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In-Person Only
Telehealth Only
Open to Both
Which in-person location fits best for your in-person appointments?
New Market, Frederick, Boonsboro
New Market
Frederick
Boonsboro
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Location
What areas of concern would you like to work on?
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Depression
Anxiety/Worry
ADHD
Grief/Loss
Postpartum/Perinatal/TTC
Trouble with school or work
Difficult family dynamics
Relationship challenges
Mood Disorders
Difficulty with Anger
Trauma
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Insurance or Self-Pay
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Will you be using insurance or self-pay?
Aetna
UHC/Optum/UMR
Carefirst
Cigna
Self-Pay
Other** Speak with staff
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Subscriber Name
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Subscriber DOB
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Front and Back of Insurance Card
Please submit the front and back of your insurance card if you plan to use insurance.
How did you hear about us?
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Want to receive the latest information from our practice and about mental health from our newsletter? (We will not spam you or sell your information)
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Email Risk Acknowledgement and Use Consent
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I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Green Valley Therapy therapists and/or office staff communicating with me via email or text message
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