Ready to make an appointment?

Complete the appointment request form below, and our team will contact you within 24–48 business hours.

Who are you seeking care for? *

ADULTS (18+) MUST COMPLETE THEIR OWN FORM AND BE THE PRIMARY CONTACT.

What type of care are you seeking for? *

Name of the minor receiving services (client) *

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

Date of birth *

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

Contact First Name *

Contact Last Name *

Contact Email *

Contact Phone *

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.

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

Yes

No

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

If there is a court order or custody agreement affecting healthcare decision-making, you must disclose it and upload a copy on this form. We rely on the information you provide to determine who may consent to treatment.

Upload Custody or Other Parental Agreement *

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

Co-Parent First and Last Name *

Co-Parent Email Address: *

Co-Parent Phone Number: *

We offer in-person appointments at any of our three office locations:

4 W. Main St. New Market, MD 21774
205 Broadway St., Suite 310 Frederick, MD 21701
9 St. Paul St. Boonsboro, MD 21713

We also offer telehealth appointments for clients anywhere in Maryland. To comply with licensing requirements, you'll just need to be physically located in Maryland during each virtual session.

How would you like to attend your appointments? *

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

For insurance information and current self-pay rates, please visit our Rates & Insurance page.

Insurance or Self-Pay *

Choose whether you'll be using insurance or paying out of pocket (self-pay).

Insurance Subscriber Name *

Insurance Subscriber Date of Birth *

Photo of the FRONT of insurance card *

Tap/Click to upload

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

Photo of the BACK of insurance card *

Tap/Click to upload

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

Do you have another insurance plan in addition to your primary insurance? *

Photo of the FRONT of secondary insurance card

Tap/Click to upload

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

Photo of the BACK of secondary insurance card

Tap/Click to upload

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

How did you hear about Green Valley Therapy? *

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

Please note: You may still receive occasional feedback or satisfaction surveys related to your care, even if you opt out of newsletters. These are not marketing communications.

I acknowledge that I have read and agree to Green Valley Therapy's Privacy Policy and Terms & Conditions.

By submitting this form, I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that Green Valley Therapy relies on this information when scheduling services and obtaining consent for treatment.

Privacy Policy
Terms and Conditions

Please note: This form is not monitored in real time. If you need immediate support, please call 911 or 988.

Green Valley Therapy

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

Accessibility Statement

Call or text (301) 381- 4586

Ready to make an appointment?

Complete the appointment request form below, and our team will contact you within 24–48 business hours.

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 the next slide using the information of the primary contact, preferably the person whose payment method will be used.

Select all the times you're generally available for weekly sessions.

More availability gives us more options when matching you with a provider.

For insurance information and current self-pay rates, please visit our Rates & Insurance page.

Please note: This form is not monitored in real time. If you need immediate support, please call 911 or 988.

Green Valley Therapy

Ready to make an appointment?

Complete the appointment request form below, and our team will contact you within 24–48 business hours.

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 the next slide using the information of the primary contact, preferably the person whose payment method will be used.

Select all the times you're generally available for weekly sessions.

More availability gives us more options when matching you with a provider.

For insurance information and current self-pay rates, please visit our Rates & Insurance page.

Please note: This form is not monitored in real time. If you need immediate support, please call 911 or 988.

Green Valley Therapy

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 the next slide using the information of the primary contact, preferably the person whose payment method will be used.