What state does the client reside in? (Currently Changing Tides Counseling & Behavioral Health, LLC provides services to residents of Maryland, District of Columbia, & Virginia). *
Client First Name *
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Client Last Name *
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Custodian/Guardian Name (if applicable)
Your answer
Primary Language *
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Client Date of Birth *
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DD
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YYYY
Client Gender *
Client Race *
Physical Address *
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Zip Code *
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Home Number *
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Cell Number *
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Is it okay to leave a voicemail on this number? *
Is it okay to send a text message to this number? *
Primary Care Provider
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Primary Care Provider Telephone #
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Services Paid By *
Required
Who is your insurance provider
Clear selection
Do you have Medi- CAL coverage? *
Do you have Medicaid coverage? *
Insurance Provider
Your answer
Insurance ID# *
Your answer
Availability *
Reason For Referral *
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How did you hear about us? *
Therapist Preference ( You can find our therapist on our website) *