Secure Online Referral Forms – Families First Counseling & Psychiatry

Patient Portal
Employee Login

Emergency Phone: 240-304-FFCP (3327) | Patient Portal

0Shopping Cart

Facebook
Mail
Instagram
LinkedIn
Rss

Welcome
Our Clinic
Patient Information
DBT
IFS
- What is IFS?
- Core Concepts of IFS
Trauma Training Program
- Have Questions?
Internship Program
- Apply Now
Contact
- Client Survey
- Employment
Patient Portal
Menu Menu

Secure Online Referral Forms

Please complete the secure online referral form below. A member of our team will contact you with instructions on accessing our patient portal to complete new patient paperwork.

"*" indicates required fields

Email address*

Phone*

Legal Name*

First Last

Preferred Name

First Last

Date of Birth*

MM

DD

YYYY

Sex*

Female

Male

Gender Identity/Expression*

Male

Female

Gender-expansive

Fluid

Other

Pronouns*

He/him

She/her

They/them

Other

Primary Language

Race*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

At which office do you wish to receive services? Please select just one from the list.*

Montgomery County

Prince George's County

Baltimore City and Baltimore County

Howard County

Calvert and Charles Counties

If legal custody has been determined by the courts, we are required by MD law to obtain a copy of the court order.

Custodian Name

First Last

Relationship to client

Custodian Home Phone

Custodian Cell Phone

Custodian Email address

Emergency Contact Name*

First Last

Emergency Contact Phone Number*

Relationship to the Client*

Do you have Medicaid?*

Yes

No

For all insurance, we require a credit card on file for co-payments. Please provide your credit card information below.By providing my credit card information, I hereby authorize Families First Counseling and Psychiatry to charge my card for co-payments and/or any remaining balance not covered under the insurance benefits provided

Credit Card Number*

Month*

Year*

Security Code*

Cardholder Name*

First Last

Cardholder Zip Code*

ZIP / Postal Code

Primary Insurance Provider*

Medical Assistance Number or Primary Insurance Policy Number*

Do you have secondary insurance?

Yes

No

Secondary Insurance Provider*

Secondary Insurance Policy Number*

School client attends if applicable

Reason for Referral (be descriptive)*

How did you hear about us?

Referral Information

Referred By*

Phone Number*

Referral Source Email*

Agency/Department

Comments

This field is for validation purposes and should be left unchanged.

Compliance & Grievance Reporting
FFCP Sliding Fee Discount Application
Howard County School Based Referral Form
Secure Online Referral Forms
Your First Visit
Formulario de Referencia Seguro
How to Get the Most From Your Treatment?
Length of Treatment
Client Rights & Responsibilities
Prescription Refills
Requesting Medical Records

FFCP Maryland Locations

FFCP Maryland
Prince George’s County Office
7474 Greenway Center Drive
Suite 202
Greenbelt, MD 20770
240-304-FFCP (3327)

FFCP Maryland
Baltimore City Office
800 N. Charles Street
Suite 450B
Baltimore, MD 21201
240-304-FFCP (3327)

FFCP Maryland Locations

FFCP Maryland
Montgomery County Office
17904 Georgia Avenue
Suite 200
Olney, MD 20832
240-304-FFCP (3327)

FFCP Maryland
Howard County Office
6410 Dobbin Road Suite F
Columbia, MD 21045
240-304-FFCP (3327)

© Copyright FFCP Maryland
Site Designed by Connect4 Consulting.

Facebook
Mail
Instagram
LinkedIn
Rss

Welcome
Our Clinic
Patient Information
DBT
IFS
Trauma Training Program
Internship Program
Contact
Patient Portal