Intake Form

Client's Personal Information
Client Name*

First NameLast Name
Sex*
Age*
Date of Birth*

MonthDayYear
Date
Which provider are you meeting with?*
If you're not sure, please contact admin@baltimoretherapycenter.com.
Are you filling this form out on behalf of yourself or your minor child?*

MyselfMy child
Check here if you are attending an anger management GROUP.
Check here if you are attending a parent education GROUP.
Is anyone else attending sessions with you?*

YesNo
Please enter the names of other parties you will be attending with:
First Name & Last Name
Client's Contact Information
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Parent/Legal Guardian's Personal Information
Name of Parent/Legal Guardian*

First NameLast Name
Sex of Parent*
Age of Parent*
Date of Birth of Parent*

MonthDayYear
Date
Parent/Legal Guardian's Contact Information
Address of Parent*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile phone of Parent*
Please enter a valid phone number.Format: (000) 000-0000.
Home phone of Parent
Please enter a valid phone number.Format: (000) 000-0000.
Email of Parent*
example@example.com
I understand the risks of using electronic methods to communicate with the Baltimore Therapy Center as described in the Consent to Treatment. I understand that I am not required to use electronic methods in order to receive treatment and that I have the right to terminate this authorization at any time.*

I request the use of electronic communication methods.I DO NOT wish to use unencrypted electronic communication methods. I understand that I have the option of avoiding electronic communications entirely, or of using secure methods such as the iPlum app or the contact form at www.baltimoretherapycenter.com.
I request the use of the following communication methods:*

E-mail (encrypted from BTC to me, not from me to BTC)Text (unencrypted in both directions)
I request the use of the following communication methods FOR MY CHILD:

E-mail (encrypted from BTC to my child, not from my child to BTC)Text (unencrypted in both directions)
How did you hear about the Baltimore Therapy Center?

Google ad (sponsored results)Google search resultschatGPT / other AIHeard about it from my partnerReferred by a friend/family memberReferred by another professionalPsychology TodayGoodTherapy.orgFacebookInstagramLinkedInOther
Name of referring party (optional)
Please select if you are receiving any of the following evaluations (optional):

bariatric psychological evaluationemotional support animal evaluationOther
Please check here if you have been referred to our program by DSS (Department of Social Services)
*

I permit the disclosure of my protected health information to the Department of Social Services.
Health Information

Please answer the following questions to the best of your ability.
Current mental health diagnoses:
Past mental health diagnoses:
Medications currently being taken:
What weight-loss methods have you previously attempted?
Release of Information
Would you like a copy of the report sent to your email address?*

YesNo
Would you like a copy of the report sent to your physician (or other party)?*

YesNo
Name of provider/practice*
E-mail address of provider/practice
example@example.com
Phone number of provider/practice*
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently seeing a mental health professional (therapist, psychiatrist, etc.)? [Please note that if yes, you may need to provide a letter from them.]*

YesNo
Have you ever been diagnosed with a mental illness?*

YesNoNot sure
Which diagnoses have you ever been given?
For what purpose are you requesting an ESA letter?*

HousingTravel (Note: as of 2021 airlines may not be required to honor ESA letters. Contact your airline for clarification.)Other
Undergoing an evaluation for an emotional support animal is not a guarantee of receiving an ESA letter. Your mental health will be evaluated and you will receive a letter only if you are found to have a mental health need for an emotional support animal.*

I accept the above terms of the ESA evaluation.
It is your responsibility to check with your airline/housing regarding whether they will accept an ESA letter and what other requirements they may have. It is recommended to verify with them well in advance of your move-in date to be sure what their requirements are. The Baltimore Therapy Center is not responsible for entities or their agents that refuse to accept an ESA letter.*

I accept the above terms of the ESA evaluation.
Terms & Conditions
Which terms?
CANCELLATION POLICY: Please note that sessions must be cancelled no less than 24 hours in advance. Sessions cancelled or rescheduled within 24 hours and no-shows will be billed the full session fee. The only exception to this rule is a documented medical emergency.*

I accept the cancellation policy.
Telemental Health
Check here if you prefer not to use telemental health services at all.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Sign & Submit
Signature*
URL
substring show
Provider name
Provider's name with numbers
Phone Number Calculation
contact info template
For last-minute issues please use the contact info you received in your session confirmation email.
Provider phone
Please enter a valid phone number.Format: (000) 000-0000.
Provider Email
example@example.com
Person 1
Person 2
folder name
raffi email temp
example@example.com
Should be Empty:

Client's Personal Information

Client's Contact Information

Parent/Legal Guardian's Personal Information

Parent/Legal Guardian's Contact Information

Health Information

Release of Information

Terms & Conditions

Telemental Health

Sign & Submit