PERSONALIZED COUNSELING AND TRAUMATIC EVENT CARE, DESIGNED JUST FOR you

Welcome

Please download the following forms and return to our Office Manager, Chris, at freestate@freestatebha.com or by using the contact us page. Forms need to be completed and returned at least 72 hours prior to your first appointment. Also, please send a picture or copy of the front and back of your insurance card.

Intake form Downloads (all clients)

Teletherapy Agreement 7 Fillable pdf (pdf)

Download

Intake Packet (FBHA) (docx)

Download

EMDR consent for Dwight Polk & Chris haugen (onlY)

EMDR Consent Form (docx)

Download

FreestateBHA

Baltimore, MD

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