If you're a new client, please complete the following forms and submit them before your first therapy session. Sessions cannot be completed without a completed, initialed, and signed intake form.
- Electronic SMR Counseling Services Therapy Intake Form.
- Printable Client Psychotherapy Intake Form. Print and fax to 240-389-1463 (Burtonsville) or 301-374-8963 (Clinton). You may also scan and email back to the office by attaching to your welcome email.
If you would like us to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
Printable Authorization to Disclose Information Form. Print and fax to 240-389-1463 (Burtonsville) or 301-374-8963 (Clinton). You may also scan and email back to the office by attaching to your office correspondences.
- Suspected child abuse or dependent adult or elder abuse, for which we are required by law to report this to the appropriate authorities immediately.
- If a client is threatening serious bodily harm to another person/s, we must notify the police and inform the intended victim.
- If a client intends to harm himself or herself, we will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, we will take further measures without their permission that are provided to me by law in order to ensure their safety.