Submit Referral

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Namefull name

Date of Birthmm/dd/yy

Client's Primary Insurance Company

Client's Primary Insurance #

Client's Secondary Insurance Company

Client's Secondary Insurance #:

Client's Street Address

Client's Phone

Services Requested

Outpatient TherapyIntensive Outpatient TherapyPsychiatric Rehabilitation Program

Briefly describe the reason that you are requesting an appointment:

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Preferred Gemini LocationWe have three locations, please select one below:

ElkridgeMt. AiryFrederick

Referral SourcePlease provide name and location of the agency from which you are referring:

YesNo

If yes, please list the agency below:

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List Other Agencies / Services Providers Involved in Client's Care

Name of Agency / Provider

Contact Name

Contact Number

Name of Agency / Provider

Contact Name

Contact Number

Name of Agency / Provider

Contact Name

Contact Number

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Contact Us

If you would like to schedule an appointment please give us a call or fill out the form to the right. If you would like more information or have questions, feel free to call us or use our email below.

If you are ready to schedule an appointment then please fill out the form. If you have questions or would like to schedule your appointment over the phone, then please contact using the phone number and email listed below:

(301) 363-1063 | phone

(301) 363-1063 | phone

(443) 545-7835 | fax