Become A Patient

Thank you for choosing Mental Health Baltimore. We are a hybrid organization offering telehealth and in-person visits!

Note: Your privacy is important to us. The information you share with us on this form will be kept confidential and part of your protected health information (PHI).

Instructions

Please complete each section of this form. This information will be used to create you an electronic medical record (EMR). Once you complete this form, it is automatically emailed back to us as completed. Completion of this form is step-1 of the new-patient intake process. Step 2 (new-patient registration) and Step 3 (new-patient appointment) details to follow.

Become A Patient

Instructions

Tell Us About Yourself

Step 1

Adult Patient Treatment Consent Form

Confidential Exchange of Information Form

Minor’s Parental Authorization

Telemed Health Informed Consent

Patient Screening and Management

Maryland Qualifying Conditions:

Become A Patient

Instructions

Tell Us About Yourself

Step 1

Adult Patient Treatment Consent Form

Confidential Exchange of Information Form

Minor’s Parental Authorization

Telemed Health Informed Consent