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Thank you in advance for completing our intake form.

*PLEASE NOTE: Complete only if you are a resident of Montgomery County.

Who Referred You to Us?
What brings you therapy? (Please check all that apply) Required

Thank You and a Member of Hearts In Mind Counseling will be in touch with you soon.

Contact Us Today

THANK YOU FOR SUBMITTING!

For more information about our providers, fees, hours of operation, or how to schedule an appointment, please contact us.

Email:  Healing@HeartsInMindCounseling.com

Phone:  202.570.1148

© 2023 by Hearts In Mind Counseling

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