Contact and Patient Information
Date
Contact Name
Contact Email
Home Phone
Cell phone
Work phone
Patient Name
Patient Address
Patient Contact numbers if different from above
Where would you like to be seen?
ELDERSBURG
WESTMINSTER
OWINGS MILLS
1425 Liberty Rd #208 79 E. Main Street #400 9199 Reisterstown Rd #105B
Eldersburg, MD 21784 Westminster, MD 21157 Owings Mills, MD 21117
Can you accept a daytime appointment of 2:00 P.M. or earlier? Yes No
Would you like to see a particular therapist? If so, who?
How were you referred to Cedar Ridge Counseling Centers?
Can you briefly explain the problem or concern. Please state if this is substance or alcohol abuse.
Insurance Information
Insurance Company Insurance Company Provider phone number
Mental Health/Substance Abuse number if different
Patient Membership or ID # Patient SS# Patient DOB
Group #
Subscriber name Subscriber SS#
Subscriber Employer Subscriber DOB
This information will be kept confidential and only shared with the Cedar Ridge Counseling Centers Intake Specialist and your selected provider. If you prefer not to submit this information through the website, please print printable version of intake form and fax to 410.549.3197 to a confidential fax or emailed to intake@cedarridgecounseling.com.
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