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 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 currently only see ages 5-60.

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

Starting in 2026, patients will need at least one in-person visit each year to meet insurance requirements. Even though Maryland law protects telehealth reimbursement, some insurance companies have been hinting at cutting back what they pay for virtual visits—creating more confusion than clarity. To keep things simple (and your care uninterrupted), we’re offering in-person appointments only for now. If you’re unsure how your plan handles telehealth, your insurance provider can give you the most up-to-date information.Click Here Learn More

Are you currently getting psychiatric treatment from someone else?

If treatment Back

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.

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

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

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Large file sizes (512 MB or larger) may be rejected. Please wait for the files to upload before clicking the submit button below.