Schedule an Appointment

Please note that this form is not to be used for emergencies; if you’re experiencing a major problem, please proceed to the nearest hospital emergency room or call 911.

We will respond within 24 business hours.

First Name *

Last Name *

Phone *

Email *

Address *

Postal code *

Which counseling service are you interested in?

Relationship to child or adolescent (if applicable)

How Would You Like To Receive Services *

In-Person Only (Baltimore City)

Telehealth Only

Open to Both

Please select your preferences for a provider

Insurance Verification

(If you plan to utilize your insurance)

Name of Insurance *

Our office accepts Hopkins EHP, United Health Care / Optum, Medical Assistance, Medicare, CareFirst, BlueCross BlueShield, Cigna / Evernorth

Insurance ID *

Date of birth *

Front of Insurance Card

Back of Insurance Card

Briefly Describe The Issue You Would Like to Work On

Please list the days and times when you are available to attend appointments?

NOTE: we don’t offer weekends–please don’t include weekends as an option.

What's the best way to contact you?

How did you hear about us? *

Would you like to receive FREE resources, mental health blogs, and news about our community offerings sent to your email?

Yes

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 LifeSpring Counseling Services therapists and/or office staff communicating with me via email or text message