Ready to make an appointment?

Fill out our appointment request form below. Our intake team will get back to you soon.

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