Home
About
Services
Patient Intake Form
Contact

Home
About
Services
Patient Intake Form
Contact

(301) 501-1114

Start Your Care

Home
About
Services
Patient Intake Form
Contact

Home
About
Services
Patient Intake Form
Contact

(301) 501-1114

Start Your Care

Submit Patient Intake Form Securely

Help us understand your needs for tailored mental health support.

A Gentle First Step Toward Feeling Better

We understand this can feel like a lot to begin with, and we are here to make it as simple and supportive as possible. We'll use the information you share to understand what you’re going through and match you with the right care. You can take your time—this is your space, and you can move through it at your own pace.

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Patient Information

Full Name*

Date of Birth*

Month

Day

Year

Address (Maryland residents only)*

Street Address City ZIP / Postal Code

Phone Number*

Email Address*

Preferred Contact Method*

Phone

Text

Emergency Contact Name & Relationship*

Emergency Contact Phone*

Insurance & Payment

Insurance Provider*

Member ID*

Group Number*

Policy Holder Name*

Self-Pay*

Yes

Reason for Visit

What brings you to therapy or mental health services today?*

How long have you been experiencing these concerns?*

Less than 1 month

1–6 months

6–12 months

Over a year

What are your primary goals for treatment?*

Mental Health History

Have you ever received mental health treatment before?*

Yes

If yes, please describe

Mental Health Other

Have you ever been diagnosed with a mental health condition?*

Anxiety

Depression

PTSD

Bipolar Disorder

ADHD

Other

diagnosed with a mental health condition

Have you ever been hospitalized for mental health reasons?*

Yes

Current Symptoms (Check all that apply)

Current Symptoms (Check all that apply)*

Anxiety or excessive worry

Panic attacks

Depression or sadness

Loss of interest

Difficulty concentrating

Sleep problems

Irritability

Mood swings

Trauma symptoms

Racing thoughts

Feeling overwhelmed

Low motivation

Social withdrawal

Other

Current symptoms

Ease Into Care

535 Main Street
Deer Park, MD 21550
300 E. Lombard St.
Baltimore, MD 21202

Phone: (301) 501-1114
Fax: (301) 334-1114
g.guthrie@oasismentalhealthpractice.com

Phone: (301) 501-1114
Fax: (301) 334-1114
Email

Home
About
Services
Patient Intake Form
Contact

Home
About
Services
Patient Intake Form
Contact