Appointment Request- The Hiding Place

Appointment Request Form

Let us know how we can help you!
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Are you pregnant?*

YesNoNot sure
Do you have any children currently living with you? If yes, please list their ages.*
Are you currently using any recreational drugs?*

YesNo
Do you smoke or use tobacco products?*

YesNo
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?*

YesNo
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.*
What date and time work best for your appointment? Important Appointment Notice:You will receive an appointment confirmation 24 hours prior to your scheduled appointment via email, text message, or phone call. If the appointment is not confirmed, it will be automatically canceled.*
Thank you for completing your appointment request. Please be sure to click the Submit button once you have finished.

You will receive a follow-up phone call, text message, or email from the Director within the next 24 hours. If you need assistance sooner, please contact The Hiding Place directly at 410-882-9130.
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Appointment Request Form