409.220.3067 | 443.398.1700 nina@thespacebetweentherapy.com PAYMENT
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It’s easy to get started

Below you will find helpful links to download and fill out your new patient forms, then upload the completed documents and submit them below.

If you prefer to fill them out in person, we are happy to assist you during your first visit.

Please contact us if you have any questions or need assistance.

Consent Form

Download and fill out the Consent Form by clicking HERE.

Upload Insurance Card & Driver's License

Please scan and the front and back of your insurance card and the front of your driver’s license, then upload and submit within the form below.

Identification Form

Download and fill out the Identification Form HERE.

Have Questions?

We are happy to help! Please contact us at Nina@thespacebetweentherapy.com.

Submit Forms Here

If you would like to submit these documents online, please fill out the information below, upload the completed documents, then click submit.

If you would like to submit or update your symptoms, please click the button below and fill out the form.

Symptoms Form

    Securely Submit Your Consent and Identification Forms Here

    Name*:

    Email*:

    Comments:

    Upload your Consent Form*:

    Upload your Identification Form*:

      Securely Submit Your Insurance Card (front and back) Here

      Name*:

      Email*:

      Comments:

      Upload your Insurance Card (Please upload both front and back)*:

        Securely Submit Your Driver's License Here

        Name*:

        Email*:

        Comments:

        Upload your Driver's License*: