New Client Enrollment Form

Let us know how we can help...

We understand this secure form is long, but it really does reduce the time it takes to secure an appointment. Once your information is received, a member of our intake team will be in contact with you within 24 business hours. If you need help filling out this form, please call us at (240) 581-1501.
Please let us know your relationship to the client*

I am the clientI am the Parent/Guardian of the client (Minors only)
Reason for contacting us*

Individual CounselingMarriage CounselingCouples' Counseling (not legally married)Pre-Marital Counseling (not billable to insurance)Family Counseling
Client Name*

First NameMiddle NameLast Name
Date of Birth (MM/DD/YYYY)*
Date of Birth

MonthDayYear
Administrative Sex
Contact Number:*
Format: (000) 000-0000.
Contact e-mail*
example@example.com
Client Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Method of Contact: Would you prefer us to contact you to schedule an appointment by email or phone?*
Insurance Information

This section is important to determine co-pays and deductibles. All of our therapists are paneled with Blue Cross Blue Shield/ Care First, Cigna, and Johns Hopkins Healthcare. All other carriers will be considered out of Network, and will have to submit their receipts to their respective insurance companies for reimbursement. Please be advised that not all insurance plans cover couples counseling.
Who is your insurance carrier?*

BCBS/CareFirst/AnthemCignaJohns Hopkins HealthcareAetnaOther will be considered out of pocket and will be responsible for paying the out-of-pocket rate at the time of sessions. We can provide a superbill for you to submit to your insurance company for potential reimbursement.I do not have insurance or will not be using my insurance
What is your Member ID?
This helps us speed up the intake process, so please submit this information. We cannot provide availability without this information.
Are you the primary subscriber on your insurance plan?

YesNo
If no, what is the primary subscriber's name?
This is required for insurance billing
If no, what is the primary subscriber's date of birth?

MonthDayYear
Date
Please upload a picture of the FRONT of your insurance card. (if you will be using insurance)

This is needed in order to schedule an appointment, an appointment will not be confirmed until we receive the front and back of your card. It will be quicker to upload it here.
Cancelof
Please upload a picture of the BACK of your insurance card.

We need this information in order to know how and where to submit claims on your behalf. It must be received before an appointment is scheduled.
Cancelof
Do you have a secondary insurance carrier?
It is essential for us to know this information, as we can only bill primary insurance for visits at this time. Not knowing if a client has a secondary insurer slows down our ability to process claims and can result in insurance denials.
What time of day works best for your appointments? Just so you know, weekend and evening appointments are typically booked first. If you have availability in the mornings or afternoons, it is easier to find availability.*

Weekday Early Mornings 8 am - 10 amWeekday Mornings 11 am - 1 pmWeekday Afternoons 2 pm - 4 pmWeekday Evenings 5 pm -8 pm (limited appointment times)Weekends (limited appointment times)Anytime will work
Please tell us any information that will assist us in scheduling an appointment for you. Including days/times you are not available or more specific details
Please indicate if you are interested in virtual or in-person sessions (all therapists offer virtual sessions; however, only select therapists offer in-person sessions). In-person sessions are held on Tuesdays, Wednesdays, and Thursdays only. Check all that apply*

Virtual OnlyIn-person OnlyCombination of bothIt does not matter
Tell Us Who You Would Like to See

Please let us know who you would like to see. Therapists with an (*) next to their names have caseloads that are full and are not accepting new clients. We cannot guarantee that your requested therapist will be available, but we will try our best.
I would like to work with... (can select multiple options)

Anyone with AvailabilityAllison Zimmerman, LCPCAlisha Peeler, LMSWAnthony Carr, LCPC - Clinical SupervisorAngela Dilao, LGPCCaleb Adu, LCSW-C - Clinical SupervisorDanielle Barnard, LMSW*Damian Chandler, LGMFTDavid Defoe, PhD, LCPC - Chief Operating OfficerDenise Defoe, LMSW - Director of Client CareDominick Pitts, LMSWDynesha Brooks, LCPCFrances Figueroa, LCPC - Clinical SupervisorJanelle Phillip, LCSW-CKenya Newsome, LGPCKevin Reed, LMSWKristyn Frazer, LICSW, LMSW*Lizeth Delcid, LMSW - HR DirectorMark Snella, LCPCMelissa Buckley, PhD, LMSWMekedes Legesse, LCPCRian Rosario-Heredia, LMSWRoma Marshall, LCSW-C - Clinical SupervisorSidney Minor, LMSWSimone Murphy, LGPCSuzane Thomas, DSW, LMSWTiffany Long, LCPC
Do you have a preference in the administrative sex of your therapist?
We ask this question in case the therapist you requested is not accepting new clients at this time.
Do you have a preference in the administrative sex of your therapist?

MaleFemaleNo preference
Have you ever been in counseling/therapy before?

YesNo
If you have a current or past mental health diagnosis, what is it?
This is confidential information and will only be used to assist our therapists during your intake process
How were you referred to Imara Counseling?

Primary Care Doctor (PCP)Mental Health Professional (counselor, social worker, therapist)Psychiatrist/Nurse PractitionerOnline Presence (social media, Therapy for Black Girls, Psychology Today)Personal ReferralOther
Would you like to subscribe to our monthly newsletter, which has tips for mental/emotional health and well-being?

YesNo
Please let us know what challenges/issues/concerns bring you to therapy.*
Please be as detailed as possible. This will help us match you with the right therapist who can be of the greatest help to you. Not all of our therapists' bios contain all of their skills and certifications, so knowing what your concern is helps us greatly. This information will not be shared with anyone other than our intake coordinator.
Please verify that you are human*
Should be Empty:

Let us know how we can help...

Insurance Information

Tell Us Who You Would Like to See