Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

Do you currently live in Maryland? *

I am only licensed to provide services to Maryland residents.

Yes-I am a Maryland resident

No-I am not a Maryland resident

Other-I am planning on moving to Maryland

Do you plan on moving in the next 3 years? *

Yes

No

Please explain your presenting concern:

Anxiety

Depression

LGBTQIA

Life transition

Grief

Relationship issues

Work related stress

Other

Would you be willing to be put on a waiting list?

Yes

No

Terms of use *

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Emerald Essence Counseling, LLC. harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Yes, I want to submit this form & agree to the terms of use.