Contact UsDIAL 911 IMMEDIATELY FOR EMERGENCIES.Do not use this form in emergencies. Please let us know your relationship to the client: * I am the client I am the client's parent/guardian (minors only) I am a professional provider/case worker Reason for Contacting HoneyTree: * Couples/Relationship Counseling (Self-Pay, Non-Insurance Only) Group (Elementary K-5th) (Waitlist Currently) Group (Middle 6th-8th) (Waitlist Currently) Group (High School) (Girls Start 01/06/25 and Boys Start 01/14/25) Individual Counseling (Ages 6-17 Only - Self-Pay, Non-Insurance) Individual Counseling (Ages 6-17 Only - Waitlist Currently - Insurance Only) Individual Counseling (Ages 18+ Only - Self-Pay, Non-Insurance) Individual Counseling (Ages 18+ Only - Waitlist Currently - Insurance Only) Reunification Therapy (Self-Pay Only, Not Covered by Insurance) Client Name * First Name Last Name Client Date of Birth * MONTH / DAY / YEAR MM DD YYYY Client's Sex * Male Female Concerns Anger Anxiety Behavioral Couples Depressive Symptoms Life Transitions School Self-Harm / SI Other Contact Name * First Name Last Name Contact Email * Contact Phone * (###) ### #### Insurance/Non-Insurance * Choose one BlueCross/BlueShield/Carefirst/Federal CIGNA Out of Network Benefits (Self-Pay & Superbill to Insurance - Rate - $180/Session) Self-Pay (Non-Insurance or Couples Counseling - Rate - $180/Session) Sliding Scale/Reduced Fee Request (Medicaid & Low Income Only) Thank you for taking this step towards your mental health journey. A member of our team will respond to you within 48 hours. We are located at:10490 Little Patuxent Pkwy, Columbia, MD