Reach out today!

If you’re ready to work toward healing and growth, contact us below.

Let’s work together to make the changes you want now. Even if you’re not sure what you want or need, we’re here for you.

Please fill out our New Client Information Form below. Our intake team will get back to you within 24 hours to start the process. If you’d like to call or text our team, the number is 301-381-4586.

For Whom Are You Seeking Counseling? *

Client's First Name (If parent requesting services for child, use child's name) *

Client's Last Name *

Client's Date of Birth (If parent requesting services for child, use child's DOB) *

Contact Phone *

Contact Email *

Is there a parental rights agreement in place for your child? *

No

Yes

If answered yes above, please complete below two questions:

Co-Parent Email Address:

Co-Parent Phone Number:

What's the Best Way to Contact You?

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Which in-person location fits best for your in-person appointments? *

Location

What areas of concern would you like to work on? *

Insurance or Self-Pay *

Insurance Subscriber Name *

Insurance Subscriber DOB *

Front and Back of Insurance Card *

Please submit the front and back of your insurance card if you plan to use insurance.

How did you hear about us? *

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

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

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Green Valley Therapy therapists and/or office staff communicating with me via email or text message

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Green Valley Therapy

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

Contact Us Today

Call or text (301) 381- 4586