MAKE A NEW REFERRAL If you have any specific questions about starting services with us, please do not hesitate to call us at (410) 685-2830. Referral's InformationReferral’s Name* First Name Last Name Email Address* Phone*Other* Potential Client InformationName of Potential Client* First Name Last Name Potential Cient’s Telephone Number*Referral For* Child and Adolescent Therapy/OMHC Child and Adolescent Therapy and Medication Management/OMHC Adult Therapy/OMHC Adult Medication Management/OMHC Telemedicine Personal Coaching Child and Adolescent PRP Adult PRP Adolescent OP/IOP DUI Education Program OMHC and PRP OMHC, PRP, and OP/IOP Medical Cannabis Certification Which service(s) did you receive* Other* MessageEmail Communication Informed Consent* I give informed consent I do not give informed consent I hereby authorize Beacon of Hope to email me to coordinate services. This authorization includes confidential, clinical, and administrative information. I understand unencrypted email could be read by a third party. Beacon of Hope may use the e-mail address listed above. 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.EmailThis field is for validation purposes and should be left unchanged. Δ If you do not wish to use the above referral form, you may call us at (410) 685-2830
