Let’s Get to Know You

We want to learn more about what’s bringing you to us. The following steps will help us better understand your experiences, goals, and care preferences. Our team will contact you shortly.

Friendly note: At this time, we provide in-office, medication management services only. We don’t offer therapy-only appointments—not because we don’t love good conversation, but because therapy takes the kind of time and continuity our schedule just doesn’t allow right now. Our focus is on helping you find the right medication support to keep you moving forward.

Disclaimer: While this website is encrypted, data security cannot be guaranteed. Communications through this site are not confidential, and there is no expectation that health data will be protected. Submitting this form does not create a provider-patient relationship. By providing your information, you consent to be contacted by M.I.N.D. Health and Wellness via email, phone, or SMS. Message frequency may vary; message and data rates may apply. By continuing on our website, you are deemed to have agreed to these terms and conditions. You can also view our privacy policy to learn more or contact us via our HIPAA-compliant platform.

Patient's Legal Name

First

Last

Legal Sex

Birth Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Confirm Email

Choose wisely as this email will be connected with your online medical record log in.

Mobile Phone

Patient's Age

We typically see patients ages 5–60, but our schedule for kiddos is currently full.

Check this box if you need to also enter another point of contact, which will help manage the patient’s medical records or assist in treatment decisions.

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How do you prefer to pay for our services?

How will we meet?

In-Office

As of June 2026, M.I.N.D. Health and Wellness is offering in-office appointments only. While Maryland law continues to protect telehealth reimbursement, some insurance companies have indicated they may reduce or limit coverage for virtual visits, creating uncertainty for both patients and providers. To help ensure consistent access to care and avoid interruptions related to changing insurance requirements, all appointments are currently being conducted in-person. If you have questions about your specific telehealth benefits or coverage requirements, please contact your insurance provider directly, as they can provide the most up-to-date information regarding your plan. Click Here Learn More

Are you currently getting psychiatric treatment from someone else?

psychiatric what see.

Please describe how we can help.

Are you currently taking any psychiatric mediations?

How did you hear about us?

This helps us know how to better help others.

Referral Details

Please share how you heard about us or who referred you.

Do you take my insurance?

You can find out what insurance plans we accept by clicking here.

For added peace of mind, you can also upload a front and back copy of your insurance card, and we’ll confirm your insurance eligibility status.

Front & Back of Insurance Cards

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