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What's next?

This form will be sent via HIPAA compliant email and our administrative staff will reply in a timely manner. If you do not hear back or cannot locate your Portal Invitation email, please check your Spam folder.

Email Address

Info@TidesOfChangeWellness.com

Office Address

7330 Grace Drive
Suite B
Columbia, MD 21044

Office painting 1.jpg

New Patient Inquiry

Name of Patient*

Age of Patient*

Email*

Phone

Please share the reason for seeking treatment

What services is the patient interested in?*

Outpatient Therapy

Dialectical Behavior Therapy (DBT)

Radically Open Dialectical Behavior Therapy (RO-DBT)

DBT/RO- DBT Skills Classes

DBT/RO Parent or Family Skills Classes

Stirring the Soul

Community Engagements

Other

Has the patient experienced any of these events within the last 6 months?*

Suicidal ideation

Self-harm

Hospitalization due to mental heath

School refusal

Eating related concerns

Perfectionism or Rigid thinking

Difficulty connecting with others

None of these

Other

Insurance Provider and is this a Medicaid or Medicare plan?

What state will you be in at the time of services?

Are you interested in virtual and/or in-person appointments?

7330 Grace Drive
Suite B
Columbia, MD 21044

Info@TidesOfChangeWellness.com

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