Monday – Friday: 8:30 AM – 6:00 PM

Phone: (301) 660 7414 | Email: [email protected]

DCS Contact Form for Services

Basic Contact Information

First Name *

Last Name *

Email Adress *

Phone Number *

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Preferred Time to Contact *

Client Information

Is this inquiry for yourself or someone else? *

Specify Relationship

Client's Full Name *

Client's Age / Date of Birth *

Gender Identity (optional)

Pronouns (optional)

Service Needs / Interests

What type of services are you interested in? (Select all that apply) *

Other (please describe)

Reason for Seeking Services

Brief description of mental health needs, concerns, or diagnosis (optional but helpful):

Insurance Information

Do you have insurance? *

Yes

No

If yes, please list your insurance provider

Member ID or upload image (optional)

File Upload

Upload Image Here

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Location Preference *

Outpatient Clinic

Residential Group Home (ID/DD or Behavioral Health)

Virtual Services (if available)

Additional Notes / Questions

Open text box for any specific concerns, preferences, or comments

Consent & Submission *

I consent to be contacted by DCS regarding services

I understand this form is not for emergencies

I have read and agree to the privacy policy