I'm interested in... *

First Name *

Last Name *

Date of Birth *

Phone *

Email *

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Which of our locations would you prefer for in-person visits? *

What concerns are you seeking care for? (Select all that apply) *

Select all that most closely describe the reason for seeking care.

Select all available times for weekly sessions. The more options selected, the sooner a provider match can be made.

Additional Scheduling Requests or Information

Use this space for any additional scheduling information you would like us to consider.

Insurance or Self-Pay *

You can visit our Rates & Insurance page to view current self-pay rates.

Insurance Subscriber Name *

Insurance Subscriber DOB *

Front and Back of Insurance Card *

If using insurance, please upload a photo of the front and back of your insurance card.

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Do you have a secondary insurance? *

How did you hear about us? *

Would you be interested in finding out more about our groups, workshops or other supports? *

Yes

No

Want to receive the latest information from our practice and about mental health from our newsletter? (We will not spam you or sell your information) *

Yes

No

Email and SMS Communication Risk Acknowledgement and Consent *

I understand that the use of email and SMS text messaging is not fully secure and may pose a risk to the privacy and confidentiality of my protected health information. I consent to Green Valley Therapy therapists and/or office staff communicating with me via email or text message for purposes related to my care, including scheduling, coordination, follow-ups, and feedback. I understand that feedback requests or satisfaction surveys may occasionally be sent for quality improvement purposes and are not marketing communications.

I agree to the terms and conditions provided by the company. By providing my phone number, I consent to receive text messages from the business.

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Green Valley Therapy

Providing In-Person Therapy in Frederick County, Maryland & Telehealth Therapy throughout Maryland

Accessibility Statement

Call or text (301) 381- 4586

Couple sessions are always self-pay, not covered by insurance. You can visit our Rates & Insurance page to view current self-pay rates.

For Couples Therapy, please fill out this form with the information of the primary contact, preferably the partner whose payment method will be used.

Select all available times for weekly sessions. The more options selected, the sooner a provider match can be made.

You can visit our Rates & Insurance page to view current self-pay rates.

Please be prepared to provide photos of the front and back of your secondary insurance card, as we will need them.

Green Valley Therapy