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Services

Spravato® Esketamine Therapy

Medication Management

Advanced Diagnostic Screening

TeleHealth Services

Genetic Testing

Conditions

Attention-Deficit/Hyperactivity Disorder

Anxiety Disorder

Depression Disorder

Bipolar Disorder

Obsessive-Compulsive Disorder

Post-Traumatic Stress Disorder

Stress & Stress Management

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<h1>Initial Intake Form</h1>

We believe in delivering compassionate, evidence-based care that empowers individuals to take control of their mental health.

 539 Benfield Road, Suite 2 & 3,
Severna Park, MD, 21146

☎︎ (410) 513-4513

866-697-4991 (Fax)

 contact@shinemaryland.com

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Open Hours

8 AM - 8 PM, Monday - Friday

8 AM - 6 PM, Saturday

Contact us today to learn more about our Mental Health Care services and how we can assist you and your loved ones.

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Shine Behavioral Health - Patient Intake Form

Thank you for submitting your information! Our team will contact you soon to schedule your appointment.

Let the real you shine through!

Patient First Name: Patient Last Name: Parent/Guardian Name (if patient is a minor or person other than patient filling out form): Birthday: Age: Email: Phone:

I live in the state of Maryland

Who we need to thank for referring you? *

Primary Care Provider Therapist Psychology Today Friend or Family Social Media Urgent Care

Who can we thank for referring you ? I would like to schedule for: *

Spravato® Esketamine Therapy Psychiatric Assessment & Medication Management Psychotherapy Advanced Diagnostic Screening by psychologist (ages 17+) Genetic Testing

I would like to be seen to address my... Type of Insurance:

Required Documents

Front of Insurance Card: Back of Insurance Card: Driver's License: