Lets Connect 1410 Crain Highway, North 2BGlen Burnie, MD 21061 +1 (410) 553-4450 admin@bayareacounseling.consulting Business Hours: Mon - Fri: 9:00 AM - 8:00 PMSaturday: By appointmentSunday: Closed Patient Portal Send Us a Message Office: Date Received:(Required) MM slash DD slash YYYY Untitled(Required) Portal Link Sent Welcome Email Sent Ins Card & ID Golden Patient Information:Name(Required) Pronouns:(Required) DOB:(Required) MM slash DD slash YYYY Address(Required) Address Line 2 City ZIP Code Primary Insurance Carrier:(Required) Insurance ID #:(Required)Secondary Insurance Carrier:(Required) Insurance ID #:(Required)Phone Number(Required)Email(Required) If Minor: Parent Name:(Required) Coparent Information:(Required) Untitled(Required) Copy of Court Agreement (any custody arrangement) Additional Contact Info.:(Required) Prior Mental Health:(Required) Yes No Current Medications with dosage:(Required)Cultural and/or Gender Expressions:(Required)REASON FOR SEEKING MENTAL HEALTH SERVICES (check all that apply)(Required) Behavior Problems/School Adjustments Trauma/PTSD Attention Deficit/Hyperactivity Disorder Family Therapy/Couples Counseling Mood D/O Custody/Court/Legal Issues Anxiety Suicidal Ideation/Homicidal Ideation Substance Use Disorder/Substance Abuse Individual Therapy Youth 8-10: ___ No SI in the last two weeks. ___ Appropriate for Telehealth. Other (please explain): Untitled Appointment Availability:(Required)Office Use OnlyAuthorization Approval:(Required) Reached/1st scheduled appointment for intake:(Required) Upload Copy of IDMax. file size: 100 MB.Upload Copy of Insurance CardMax. file size: 100 MB.PhoneThis field is for validation purposes and should be left unchanged.