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
YesNoNot sure
Do you have any children currently living with you? If yes, please list their ages.*
YesNo
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.*
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.*
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 24 hours to schedule your appointment. If you cannot wait 24 hours and need same-day placement, please contact us directly at 410-882-9130.

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

Appointment Request Form