24-Hour Crisis Hotline: (410) 685-2830, Press Option 5
24-Hour Compliance Hotline: (410) 685-2830, Press Option 6

Appointment Request

If you are a current client, you may complete this form to request an appointment with your treating provider. If you need to cancel or reschedule an existing appointment, please contact our practice directly by calling (410) 685-2830.

If you are experiencing a medical emergency, please call 911 or go to your nearest emergency room.

For a non life-threating emergency or crisis, you may call our 24-hour Crisis Hotline: (410) 685- 2830, press 5

Please note, your request will be processed within 1-2 business days.

Information on this page is secure. We value your privacy.

  • Client Information

  • MM slash DD slash YYYY
  • :

  • Healthcare Insurance Information

  • Maryland Medicaid (11 Digit Numbers): 0000000000
  • Medicare
  • Self-Pay Fee: $

  • Appointment Request

    We cannot guarantee exact scheduling, but we will do our best to accommodate the client's wishes.
  • (i.e. home, school)

  • 1st Appointment Date Request

  • MM slash DD slash YYYY
  • :

  • 2nd Appointment Date Request

  • MM slash DD slash YYYY
  • :
  • I hereby authorize Beacon of Hope to contact me to schedule an appointment. This authorization includes confidential, clinical, and administrative information. I understand unencrypted email could be read by a third party. Beacon of Hope may call and/or text the telephone number listed above. I accept full financial responsibility for all of the text message charges sent to the telephone number I provided. This informed consent goes into effect immediately and expires one year from this date or when I request it to end. Our administrative staff strives to respond in a timely manner to your inquiry. Please allow up to 48 hours or two business days for a response. Thank you.
  • This field is for validation purposes and should be left unchanged.

If you do not wish to use the above referral form, you may call us at (410) 685-2830