Contact Us

Tell us what's on your mind and we'll handle the rest.

Please correct the errors described below.

First and Last Name

Please enter your first and last name.

Phone Number

Please enter your phone number.

Email address

Insurance

Please select your current insurance provider

Are you a current client?

State of Residence

I'm interested in...

Are you open to virtual appointments?

Yes No

I'm seeking services for...

How old is your child?

What are you looking for support with?

Anxiety or Worry

Trouble focusing or possible ADHD

Grief or major life changes

Mood swings or irritability

Possible bipolar symptoms or big shifts in mood and energy

Thoughts or fears related to hallucinations or unusual beliefs

Alcohol or substance use

Depression or feeling low most days

Sleep issues or insomnia

Trauma or past experiences affecting daily life

Feeling numb, disconnected, or stuck

Eating concerns that feel out of your control

Intense emotions that feel hard to manage

Couples Counseling (PRIVATE PAY ONLY)

Other

What are you looking for support with?

Anxiety or Worry

Trouble focusing or possible ADHD

Grief or major life changes

Mood swings or irritability

Possible bipolar symptoms or big shifts in mood and energy

Thoughts or fears related to hallucinations or unusual beliefs

Alcohol or substance use

Depression or feeling low most days

Sleep issues or insomnia

Trauma or past experiences affecting daily life

Feeling numb, disconnected, or stuck

Eating concerns that feel out of your control

Intense emotions that feel hard to manage

Managing Current Medication

Questions about starting medication

Other

What days usually work best for you for appointments?

Monday

Tuesdays

Wednesdays

Thursdays

Fridays

No preference

What times usually work best for you for appointments?

Morning

Afternoon

Evening

No preference

How can we help?

Your information will be encrypted.

Serenity Place, LLC

(301)690-8008
www.SerenityPlaceLLC.com

Loading...

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Close

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Copyright © 1999-2026 Hush Communications Canada Inc.

Terms of service
Privacy policy

Hide