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All Inquiring Clients Must Submit This Inquiry Form

Insurance & Payment Information: We are out of network with all insurance plans.
You can check your out-of-network benefits using our secure Thrizer benefits tool here. For a detailed overview of how payments and out-of-network reimbursement work in our practice, please visit our Financial Information page.

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Your Name *

First

Last

Email *

May we add you to our email list?YesNo

Phone Number *

What is your preferred method of contact? *

• Email
• Phone call
• Text message
• No preference

If you prefer email communication, please add info@mccounselingcenter.com to your contacts and check your spam folder if you do not receive a response within 24 business hours. Please note that we may follow up by phone if additional information is needed

How did you hear about our practice? *

I am seeking services for:

• Myself
• A minor in my care

Name of minor in your care *

First

Last

What is the legal status between you and your child's other parent? *

• Married / partnered
• Separated or divorced
• Single parent (there is no other parent)
• Other

Please describe the legal status between you and your child's other parent. *

Please list the names and emails of all legal guardians: *

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

Do you have a court order or legal documentation establishing your authority to consent to treatment for this minor? *

• Yes
• No

How is your legal authority to care for this minor established? *

• Joint legal custody
• Sole legal custody
• Legal guardianship
• Other

What legal arrangement and documentation do you have establishing authority to consent to treatment for this minor *

Are you willing to provide a copy of your custody order, guardianship order, or legal documentation? *

• Yes
• No
• N/A

In order to authorize mental health treatment for the minor in your care, Maryland law requires that you have legal authority to consent to treatment, whether through sole or joint legal custody or court-established guardianship. You will be asked to provide a copy of your most recent custody degree, guardianship order, or other legal documentation that establishes your authority to consent to treatment. If you have joint legal custody, both legal guardians must consent to treatment before services can begin.

What type of therapy services are you seeking? *

• Individual Therapy
• Couples Therapy, Family Therapy, or Parent Coaching
• Groups
• Mental Wellness Check
• I need help figuring out what is best for me or my family

You may select any or all options.

Are the members of your family aware that you're seeking support? *

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

Please list the names and email addresses of each individual who will be participating in services *

Please select the group you are interested in *

• RO-DBT Skills Class
• DBT Skills Group

Please list the age(s) of all individuals seeking services. *

If you are seeking services for more than one person, such as couples counseling, family therapy, or parent coaching, please list the age of each individual who will be participating in services

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

• None
• Self-harm
• Suicidal Ideation
• Substance Use
• Running Away
• Physical Aggression
• Other (please describe in additional information box below)

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

What is your preference for therapy sessions? *

• In person
• Telehealth
• Open to either

What state do you live in? *

• MD
• DC
• VA
• PA
• Other

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

Please list the state you currently live in *

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

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.

If you have questions about fees, insurance, or reimbursement, please review our Financial Information page for detailed guidance.

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Contact Us Today To Start Therapy In Maryland

For questions about any of our services or therapists, please check out our resources online, or fill out an inquiry form above. We do our best to respond to messages within 48 business hours. Thank you for your patience.

According to the Federal No Surprises Act of 2022, you have a right to receive a Good Faith Estimate for how much your medical care will cost.

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