Appointment Request- The Hiding Place

Appointment Request Form

Let us know how we can help you!
Full Name

First NameLast Name
Age
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Are you pregnant?
Do you have any children currently living with you? If yes, please list their ages.
Are you currently using any recreational drugs?
Do you smoke or use tobacco products?
Do you take any medications on a regular basis? If so, please list the medications and the conditions they are prescribed for:
Do you have any known physical, cognitive, or developmental disabilities that may require special accommodations? If yes, please explain.
Are you currently experiencing any mental health concerns, or are you receiving treatment for mental health–related conditions? If yes, please provide a brief explanation.
Are you currently a victim of domestic violence?
Have you ever been convicted of a crime? If yes, please provide a brief explanation.
Do you have any pending court cases? If yes, please provide a brief explanation.
Please tell us a little bit about your situation.
Thank you for completing your appointment request, Please note that this is NOT an intake appointment. Be sure to click the Submit button once you have finished.

You will receive a follow-up phone call, text message, or email within 24 hours to schedule your initial appointment. If you have any questions, please contact us directly at 410-882-9130 from Monday through Friday 8:30 am to 4:30 pm.

Main Office Address (for appointments):
1607 Cromwell Bridge Rd
Parkville, MD 21234
Should be Empty:

Appointment Request Form