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Your Name *

First

Last

Email *

May we add you to our email list?

Phone Number *

How did you hear about our practice?

Important Note: We Do Not Accept Health Insurance *

I understand that Montgomery County Counseling Center is Out-of-Network and does not accept insurance directly. I agree that I will be responsible for paying for my therapy, and then submit my Out-of Network reimbursement claims through my insurance company.

Note: If you have questions or need help understanding your options, please email info@mccounselingcenter.com for assistance from our clinical intake coordinator.

What type of therapy services are you seeking? *

You may select any or all options.

Your Child's Name *

First

Last

Is your partner on board and aware that you're seeking couples counseling? *

Yes
No
It’s complicated (please describe in additional information box below)

Your Partner's Name *

First

Last

Your Partner's Email *

Which DBT skills group are you interested in? *

Please list your age and/or the age(s) of those seeking services: *

If you are interested in family therapy, please list ages of all family members involved.

Please list the names of all legal guardians: *

Per Maryland state law, all legal guardians must consent to treatment.

Are you separated or divorced? *

Yes
No
Other

Please describe: *

Please indicate your custody status: *

Joint legal custody
Sole legal custody
Other

If the child is a minor and there is an active court order/legal parenting plan involving the child, are you willing to provide a copy of the court order? *

Yes
No
N/A

In order to authorize mental health treatment for your child, Maryland law requires that you have either sole or joint custody of your child. Before scheduling an intake appointment with our office, you will be asked to provide a copy of the most recent custody decree that establishes custody rights of you and the other parent, or otherwise demonstrates that you have the right to authorize treatment for your child.

What is your child's level of willingness to engage in therapy? *

What, if any, safety risks are you concerned about? *

If you or you child are in imminent risk, please call 988 or go to your local crisis center.

What, if any, treatment have you already received? *

Please describe any current or recent services including outpatient therapy, psychiatry, IOP, PHP, or hospitalizations.

What are you hoping to achieve in therapy? *

Please provide any additional information you'd like us to have:

When is the best time to reach you? *

Preferred contact method: *

Note: If you prefer email, please add info@mccounselingcenter.com to your contacts and check your spam folder if you do not hear from us within 24 business hours. Also know that we may need to call you for more information if deemed necessary.

What is your preference for therapy sessions? *

In-person
Telehealth
Open to either

Our intake specialist can help determine which method is clinically appropriate for your needs.

What state do you live in? *

For telehealth appointments, we must match you with a clinician licensed in your state.

If you were referred to a specific clinician or have already reviewed our therapists’ bios, who are you interested in working with?

Specific Clinician Name

All Inquiring Clients Must Submit This Inquiry Form

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