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  • ABOUT US
    • OUR LEADERSHIP
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FORMS

Patient Forms

Select a form below to download a copy to fill out.

Forms for Clients:

PRP Consent Packet for Adults

PRP Consent Packet for Children/Adolescents

Therapy/Medication Management Consent Packet for Adults

Therapy/Medication Management Consent Packet for Children/Adolescents

Request Form for Client Records

Telehealth Consent Form

Third Party Release of Information Form

Forms for Providers:

Referral Form - Therapy

Referral Form - Psychiatric Rehabilitation Program Services (PRP)

*Please note: Clients must be referred by their licensed mental health professional. Clients must be in ongoing psychotherapy to enroll into PRP services.

Referral Form - Psychiatry

Laurel Office
14440 Cherry Lane Court
Suite 208
Laurel, Maryland 20707
Phone: 301.604.1458
Fax: 301.604.1459

Hagerstown Office
20 West Washington Street
Suite 503
Hagerstown, Maryland 21740
Phone: 301.393.3949
Fax: 301.745.3482

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