Appointment Request (old)

To schedule an individual, children, couples or family therapy appointment or to obtain additional information about any of these counseling services, please fill out the form below or leave a message on 410-777-8151 ext 102. Ellen Talbert, Intake Coordinator will contact you by phone or email to get information in order to schedule an appointment.

Please include the following information:

1. Client name and date of birth
2. Policy holder and date of birth
3. Type of insurance; member ID and group number
4. Home address
5. Information regarding why you are seeking services.

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.