Client Personal Information

Client’s Name

Date of Birth:

Address:

City:

State:

Zip Code:

Telephone #:

Your email:

Preferred Methods of Communication:
Phone CallTextEmail

In a brief description, please let us know why you are seeking professional therapy:

Emergency Contact Information

Emergency Contact Name:

Relationship to Client:

Emergency Contact Phone Number:

Client Print Name:

Date:

Client/Parent Guardian Signature:

General Policies

Confidentiality and Privacy:

Your privacy is important to us. We use secure and encrypted telehealth platforms to conduct our sessions.

Please ensure you are in a private and secure location during sessions to maintain confidentiality.

Technology Requirements:

Ensure you have a reliable internet connection and access to a computer, tablet, or smartphone with a functioning camera and microphone.

Familiarize yourself with the telehealth platform and test it before our scheduled sessions.

Appointment Scheduling:

Sessions are scheduled in advance. To reschedule or cancel, please provide at least 24 hours' notice.

Late arrivals will not extend the session beyond the scheduled end time.

Fees and Payments:

Discuss and agree upon fees before the first session. Payment is expected before or at the time of each session.

At Mental Health Services of Maryland we accept credit card payments and Flexible Spending Accounts (FSA) can be used to pay for psychotherapy. Invoices and receipts will be provided upon request.

Emergencies and Crisis Situations:

In case of an emergency or crisis, call your local emergency services or go to the nearest emergency room.

Our telehealth services are not suitable for immediate crisis intervention.

An initial breach of any of these policies will lead to a warning. Subsequent violations may result in termination from the practice.

If any questions or concerns, please do not hesitate to reach out to our Therapist, Diana Martins at dmartins@mhsmd.com or by telephone at (301) 284-0350.

For crisis assistance, please call the Montgomery County Crisis Center at (240) 777-4000.