I'm interested in... *

Name of the minor receiving services (client)

If you are a parent/guardian requesting services for child, enter child's name.

Date of Birth (of the minor receiving services) *

If you are a parent/guardian requesting services for child, enter child's DOB

Contact First Name *

Parent/guardian contact

Contact Last Name *

Parent/guardian contact

Contact Phone *

Parent/guardian contact

Contact Email *

Parent/guardian contact

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.

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

No

Yes

This refers to any court order or custody agreement that affects who can make healthcare decisions or consent to treatment for the child.

Upload Custody or Other Parental Agreement *

Click to upload

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

Other Parent's Full Name *

If not applicable, put N/A.

Other Parent's Email Address: *

If not applicable, put N/A.

Other Parent's Phone Number: *

If not applicable, put N/A.

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?

If you have secondary insurance, enter the provider name. Otherwise, enter “none.”

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

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