Today M-D-Y
[HIDDEN]1. Filling out for a:
Practitioner
Treatment Program
Private Practitioner
Provider
[HIDDEN]2. Choose which applies:
New sign up
Information change
3. Name of provider (program or individual practitioner):
3a. Agency contact person--Name of person completing this application to be contacted for follow up.
3a1. Contact Person First Name:
3a2. Contact Person Last Name:
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Allegany County Anne Arundel County Baltimore City Baltimore County Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince Georges County Queen Anne's County St. Mary's County Somerset County Talbot County Washington County Wicomico County Worcester County
Copy of License included COMAR 10.63 BHA Licensing Department
* must provide value
11. Enrolled with Medicaid:
Yes
No
[HIDDEN]11a. Enrolled with Medicaid and the problem gambling reimbursement program:
Yes
No
12. Would you be interested in clinical training?
Yes
No
Please complete the section below to indicate who persons should contact to make an initial appointment for No Cost Treatment.
This information will be listed on the MD Problem Gambling Referral Directory is used by the MD Problem Gambling Helpline for help seeker referrals; additionally, it is accessible on The Center's websites. Please alert The Center if there are any changes to your agency location, hours, etc.
20. How many locations are you listing?
______
______
______
______
______
______
______
Contact First Name for appointment
Contact Last Name for appointment
19. Phone Number to call for appointment
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Allegany County Anne Arundel County Baltimore City Baltimore County Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince Georges County Queen Anne's County St. Mary's County Somerset County Talbot County Washington County Wicomico County Worcester County Telehealth (Only) Other
13. Please indicate the days, then hours of operation:
Open
Closed
13a1a. Monday standard opening
Now H:M
AM
PM
13a1b. Monday standard closing
Now H:M
AM
PM
13a3a. Please specify other arrangements:
Open
Closed
13b1a. Tuesday standard opening
Now H:M
AM
PM
13b1b. Tuesday standard closing
Now H:M
AM
PM
13b3a. Please specify other arrangements:
Open
Closed
13c1a. Wednesday standard opening
Now H:M
AM
PM
13c1b. Wednesday standard closing
Now H:M
AM
PM
13c3a. Please specify other arrangements:
Open
Closed
13d1a. Thursday standard opening
Now H:M
AM
PM
13d1b. Thursday standard closing
Now H:M
AM
PM
13d3a. Please specify other arrangements:
Open
Closed
13e1a. Friday standard opening
Now H:M
AM
PM
13e1b. Friday standard closing
Now H:M
AM
PM
13e3a. Please specify other arrangements:
Open
Closed
13f1a. Saturday standard opening
Now H:M
AM
PM
13f1b. Saturday standard closing
Now H:M
AM
PM
13f3a. Please specify other arrangements:
Open
Closed
13g1a. Sunday standard opening
Now H:M
AM
PM
13g1b. Sunday standard closing
Now H:M
AM
PM
13g3a. Please specify other arrangements:
Please specify levels of care:
14. Please specify services provided for Gambling Disorder
15. Please specify documents required for first appointment
16. Please specify if you provide support for persons with special requirements
16b-e. Language services provided:
16e1. Specify Other Languages (excluding Spanish):
21. Contact Person First Name for appointment:
22. Contact Person Last Name for appointment:
23. Phone number to call for appointment:
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Allegany County Anne Arundel County Baltimore City Baltimore County Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince Georges County Queen Anne's County St. Mary's County Somerset County Talbot County Washington County Wicomico County Worcester County Telehealth (Only) Other
30. Alternative Phone Number
31. Please indicate the days, then hours of operation:
Open
Closed
31a1a. Monday standard opening
Now H:M
AM
PM
31a1b. Monday standard closing
Now H:M
AM
PM
31a3a. Please specify other arrangements:
Open
Closed
31b1a. Tuesday standard opening
Now H:M
AM
PM
31b1b. Tuesday standard closing
Now H:M
AM
PM
31b3a. Please specify other arrangements:
Open
Closed
31c1a. Wednesday standard opening
Now H:M
AM
PM
31c1b. Wednesday standard closing
Now H:M
AM
PM
31c3a. Please specify other arrangements:
Open
Closed
31d1a. Thursday standard opening
Now H:M
AM
PM
31d1b. Thursday standard closing
Now H:M
AM
PM
31d3a. Please specify other arrangements
Open
Closed
31e1a. Friday standard opening
Now H:M
AM
PM
31e1b. Friday standard closing
Now H:M
AM
PM
31e3a. Please specify other arrangements:
Open
Closed
31f1a. Saturday standard opening
Now H:M
AM
PM
31f1b. Saturday standard closing
Now H:M
AM
PM
31f3a. Please specify other arrangements
Open
Closed
31g1a. Sunday standard opening
Now H:M
AM
PM
31g1b. Sunday standard closing
Now H:M
AM
PM
31g3a. Please specify other arrangements
Please specify levels of care:
32. Please specify services provided for Gambling Disorder
33. Please specify documents required for first appointment
34. Please specify if you provide support for persons with special requirements
34b-e. Language services provided
34e1. Specify Other languages (excluding Spanish):
35. Contact Person First Name for appointment:
36. Contact Person Last Name for appointment:
37. Phone number to call for appointment :
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Allegany County Anne Arundel County Baltimore City Baltimore County Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince Georges County Queen Anne's County St. Mary's County Somerset County Talbot County Washington County Wicomico County Worcester County Telehealth (Only) Other
44. Alternative Phone Number:
45. Please indicate the days, then hours of operation:
Open
Closed
45a1a. Monday standard opening:
Now H:M
AM
PM
45a1b. Monday standard closing:
Now H:M
AM
PM
45a3a. Please specify other arrangements
Open
Closed
45b1a. Tuesday standard opening
Now H:M
AM
PM
45b1b. Tuesday standard closing
Now H:M
AM
PM
45b3a. Please specify other arrangement
Open
Closed
45c1a. Wednesday standard opening
Now H:M
AM
PM
45c1b. Wednesday standard closing
Now H:M
AM
PM
45c3a. Please specify other arrangements:
Open
Closed
45d1a. Thursday standard opening
Now H:M
AM
PM
45d1b. Thursday standard closing
Now H:M
AM
PM
45d3a. Please specify other arrangements
Open
Closed
45e1a. Friday standard opening
Now H:M
AM
PM
45e1b. Friday standard closing
Now H:M
AM
PM
45e3a. Please specify other arrangements
Open
Closed
45f1a. Saturday standard opening
Now H:M
AM
PM
45f1b. Saturday standard closing
Now H:M
AM
PM
45f3a. Please specify other arrangements
Open
Closed
45g1a. Sunday standard opening
Now H:M
AM
PM
45g1b. Sunday standard closing
Now H:M
AM
PM
45g3a. Please specify other arrangements
Please specify levels of care:
46. Please specify services provided for Gambling Disorder
47. Please specify documents required for first appointment
48. Please specify if you provide support for persons with special requirements
48b-e. Language services provided
48e1. Specify Other languages (excluding Spanish):
49. Contact person First Name for appointment :
50. Contact person Last Name for appointment:
51. Phone number to call for appointment:
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Allegany County Anne Arundel County Baltimore City Baltimore County Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince Georges County Queen Anne's County St. Mary's County Somerset County Talbot County Washington County Wicomico County Worcester County Telehealth (Only) Other
58. Alternative Phone Number:
59. Please indicate the days, then hours of operation:
Open
Closed
59a1a. Monday standard opening
Now H:M
AM
PM
59a1b. Monday standard closing
Now H:M
AM
PM
59a3a. Please specify other arrangements:
Open
Closed
59b1a. Tuesday standard opening
Now H:M
AM
PM
59b1b. Tuesday standard closing
Now H:M
AM
PM
59b3a. Please specify other arrangements:
Open
Closed
59c1a. Wednesday standard opening
Now H:M
AM
PM
59c1b. Wednesday standard closing
Now H:M
AM
PM
59c3a. Please specify other arrangements:
Open
Closed
59d1a. Thursday standard opening
Now H:M
AM
PM
59d1b. Thursday standard closing
Now H:M
AM
PM
59d3a. Please specify other arrangements:
Open
Closed
59e1a. Friday standard opening
Now H:M
AM
PM
59e1a. Friday standard closing
Now H:M
AM
PM
59e3a. Please specify other arrangements:
Open
Closed
59f1a. Saturday standard opening
Now H:M
AM
PM
59f1b. Saturday standard closing
Now H:M
AM
PM
59f3a. Please specify other arrangements:
Open
Closed
59g1a. Sunday standard opening
Now H:M
AM
PM
59g1b. Sunday standard closing
Now H:M
AM
PM
59g3a. Please specify other arrangements:
Please specify levels of care:
60. Please specify services provided for Gambling Disorder
61. Please specify documents required for first appointment
62. Please specify if you provide support for persons with special requirements
62b-e.Language services provided:
62e1. Specify Other languages (excluding Spanish):
63. Contact Person First Name for appointment:
64. Contact Person Last Name for appointment :
65. Phone number to call for appointment:
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Allegany County Anne Arundel County Baltimore City Baltimore County Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince Georges County Queen Anne's County St. Mary's County Somerset County Talbot County Washington County Wicomico County Worcester County Telehealth (Only) Other
Alternative Phone Number:
72. Please indicate the days, then hours of operation::
Open
Closed
72a1a. Monday standard opening
Now H:M
AM
PM
72a1b. Monday standard opening
Now H:M
AM
PM
72a3a. Please specify other arrangements:
Open
Closed
72b1a. Tuesday standard opening
Now H:M
AM
PM
72b1b. Tuesday standard closing
Now H:M
AM
PM
72b3a. Please specify other arrangements:
Open
Closed
72c1a. Wednesday standard opening
Now H:M
AM
PM
72c1b. Wednesday standard closing
Now H:M
AM
PM
72c3a. Please specify other arrangements:
Open
Closed
72d1a. Thursday standard opening
Now H:M
AM
PM
72d1b. Thursday standard closing
Now H:M
AM
PM
72d3a. Please specify other arrangements:
Open
Closed
72e1a. Friday standard opening
Now H:M
AM
PM
72e1b. Friday standard closing
Now H:M
AM
PM
72e3a. Please specify other arrangements:
Open
Closed
72f1a. Saturday standard opening
Now H:M
AM
PM
72f1b. Saturday standard closing
Now H:M
AM
PM
72f3a. Please specify other arrangements:
Open
Closed
72g1a. Sunday standard opening
Now H:M
AM
PM
72g1b. Sunday standard closing
Now H:M
AM
PM
72g3a. Please specify other arrangements:
Please specify levels of care:
73. Please specify services provided for Gambling Disorder
74. Please specify documents required for first appointment
75. Please specify if you provide support for persons with special requirements
75b-e. Language services provided:
75e1. Specify Other languages (excluding Spanish):
76. Contact Person First Name for appointment:
77. Contact Person Last Name for appointment:
78. Phone number to call for appointment :
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Allegany County Anne Arundel County Baltimore City Baltimore County Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince Georges County Queen Anne's County St. Mary's County Somerset County Talbot County Washington County Wicomico County Worcester County Telehealth (Only) Other
85. Alternative Phone Number:
86. Please indicate the days, then hours of operation:
Open
Closed
86a1a. Monday standard opening
Now H:M
AM
PM
86a1b. Monday standard closing
Now H:M
AM
PM
86a3a. Please specify other arrangements:
Open
Closed
86b1a. Tuesday standard opening
Now H:M
AM
PM
86b1b. Tuesday standard closing
Now H:M
AM
PM
86b3a. Please specify other arrangements:
Open
Closed
86c1a. Wednesday standard opening
Now H:M
AM
PM
86c1b. Wednesday standard closing
Now H:M
AM
PM
86c3a. Please specify other arrangements:
Open
Closed
86d1a. Thursday standard opening
Now H:M
AM
PM
86d1b. Thursday standard closing
Now H:M
AM
PM
86d3a. Please specify other arrangements:
Open
Closed
86e1a. Friday standard opening
Now H:M
AM
PM
86e1b. Friday standard closing
Now H:M
AM
PM
86e3a. Please specify other arrangements:
Open
Closed
86f1a. Saturday standard opening
Now H:M
AM
PM
86f1b. Saturday standard closing
Now H:M
AM
PM
86f3a. Please specify other arrangements:
Open
Closed
86g1a. Sunday standard opening
Now H:M
AM
PM
86g1b. Sunday standard closing
Now H:M
AM
PM
86g3a. Please specify other arrangements:
Please specify levels of care:
87. Please specify services provided for Gambling Disorder
88. Please specify documents required for first appointment
89. Please specify if you provide support for persons with special requirements
89b-e. Language services provided:
89e1. Specify Other languages (excluding Spanish):
90. Contact Person First Name for appointment:
91. Contact Person Last Name for appointment:
92. Phone Number to call for appointment:
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Allegany County Anne Arundel County Baltimore City Baltimore County Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince Georges County Queen Anne's County St. Mary's County Somerset County Talbot County Washington County Wicomico County Worcester County Telehealth (Only) Other
99. Alternative Phone Number
100. Please indicate the days, then hours of operation:
Open
Closed
100a1a. Monday standard opening
Now H:M
AM
PM
100a1b. Monday standard closing
Now H:M
AM
PM
100a3a. Please specify other arrangements:
Open
Closed