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At Embracive Wellness, healing begins with an embrace.

Thank you for reaching out. Completing this form helps us understand your needs, values, and goals, and determine whether Embracive Wellness is a supportive fit for you or your loved one. Please share what you feel comfortable sharing.

Call: 443.822.2555
Email: info@weembracewellness.com

All fields with an "*" are required to submit this form

About You

Who are you reaching out for?

MyselfSomeone Else

If someone else, please share your relationship (e.g., parent, partner, caregiver, advocate)

Relationship

* First Name

* Last Name

Age

* Email Address

* Phone Number

* Preferred Way to Connect

EmailPhone CallText Meaasage

Location

City

State

Country

How Can We Support You?

* Have you participated in therapy or healing services before?

YesNo

* Which services are you interested in exploring?

(Select At Least One)

Individual TherapyFamily or Relationship TherapyAfrican-Centered / Culturally Responsive TherapyWellness or Healing-Focused ServicesOther (please specify)

Other Services (Response Optional)

* What are you hoping to gain or work towards through therapy and healing?

(Response Required)

Is there anything about your identity, culture, background, faith, family, or lived experience that you would like us to know?

(Response Optional)

Are there any current stressors, concerns, or challenges you would like us to be aware of as we review your request?

(Response Optional)

Scheduling & Practical Details

* General Availability

Time range(s):

Preferred Session Format

Virtual / TelehealthIn-person

Payment Preference

Self-PayInsurance (please list provider if applicable)

Provider

* How did you learn about Embracive Wellness?

Referral (friend, family, provider, community organization)Online search (Google, website, social media)Community event or outreachOther (please share)

Other (Please Share)

Is there anything else you’d like us to know before we respond?

Additional Information

Accessibility & Comfort

Do you have any needs or preferences that would help you feel more comfortable and supported in therapy?

(Examples: accessibility needs, communication preferences, cultural or spiritual considerations) (Response Optional)

Consent & Important Information

Both consent statements must be checked to submit this form

* I understand that this contact form is not a secure patient portal and should not be used for urgent or emergency situations. If I am experiencing a mental health emergency or am in immediate danger, I will contact local emergency services or a crisis hotline.* I consent to be contacted by Embracive Wellness using the information I have provided.

Thank you for taking this step toward your healing and well-being. We honor your courage, your story, and your willingness to reach out. Someone from Embracive Wellness will respond with care and intention as soon as possible.

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