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

Email address

Phone number

Insurance Name

Insurance Number

Date of BIRTH

Referral Source

Referral Source (name and company)

Phone number

Email Address

Presenting Concerns/Issues/Problems:

ex depression, relationship issues etc

Services

Services Requested

Therapy (office based)

Therapy ( in home services)

Medication Management

12 Hour DWI

Substance Use Services (OP or IOP)

Youth Anger Management

Anger Management

Complete registration for at https://www.firstcccenter.com/anger-management-baltimore

PRP

Seperate referral must be completed by mental health professional. Referral form can be found https://www.firstcccenter.com/prp

File attachments psychosocial, discharge summary etc or can be faxed to 410 779 9400

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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.

410 929 4793
www.firstcccenter.com
600 Reistertown Rd Suite 402, Pikesville, MD, 21208