Request Service(s)

Emergency Assistance

If this is an emergency, call:

911
Baltimore County Crisis : 410-931-2214
Baltimore City Crisis Response: 410-433-5175

Client Information

First name

Last name

Guardian Name and Contact Information

Email address

Phone number

Insurance Name

Insurance Number

If you have commercial insurance, please contact your insurance company to verify your mental health benefits.

Date of Birth

Legal Gender

Appointment Availability

Please provide several days and times you are available for appointments.

Therapist Preference

View our providers at https://www.firstcccenter.com/team If you do not have a preference, enter “No preference” or leave blank.

Check here if this is a school based referral

Referral Source

Referral Source (name and company)

Phone number

Email Address

Was client and/or parent informed of this referral?

Yes

Presenting Concerns/Issues/Problems:

ex depression, relationship issues etc

Services

Services Requested

Therapy

Medication Management

School-based substance and/or mental health services

Youth Anger Management

Adult Anger Management

File attachments Insurance card, Identification, Discharge summary etc or can be faxed to 410 779 9400

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Please upload a file

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First Choice Counseling Center

First Choice Counseling is not only the name of our agency; it encompasses our guiding principle of always putting our clients first while providing quality customized services with respect and integrity. Mission Statement: The mission of First Choice Counseling Center is to promote individualized wellness by providing accessible and quality behavioral health services that emphasizes trust, respect, confidentiality and compassion.

410 989-9922
www.firstcccenter.com
team
9199 Reisterstown Rd Suite 105B, Owings Mills, MD, 21117, United States