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New Psychiatry Client Contact Form

This form is for individuals seeking medication management.

Looking for therapy? Please complete our New Individual Client Form!

Who are you seeking services for?
Gender

Thanks for submitting!​ We will email you our intake paperwork and an invitation to our telehealth platform, TherapyPortal, within two business days. ​If you do not receive our intake paperwork in that timeframe, please give us a call at 410-324-2216.

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "submit" you agree to hold Heart & Mind Counseling Services harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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