• patient-forms

    Optimism is the faith that leads to achievement. Nothing can be done without hope and confidence.

    - Helen Keller

  • Patient Forms

    The following forms and corresponding instructions are provided for your convenience. Please note that these patient forms may not be the appropriate forms for all patients in all circumstances.


    Patient Registration Forms

    Save time during your first appointment by completing the Patient Registration Forms prior to your visit. Simply print out the Patient Registration Forms, fill in the information requested, and bring the completed forms with you to your appointment.

    PDF Icon Patient Registration Form

    PDF Icon Notice of Privacy Practices Acknowledgment

    PDF Icon Medicare Waiver


    Other Forms

    PDF Icon Authorization to Discuss Medical Information

    PDF Icon Request to Send Medical Records to Potomac Psychiatry

    PDF Icon Psychological Assessment Questionnaire

    Our offices are conveniently accessible from the following communities:

    Maryland (MD):
    Bethesda 20814 - Bethesda 20816 - Bethesda 20817 - Chevy Chase 20815 - Colesville 20904 - Cabin John 20815 - Glen Echo 20812 - Gaithersburg 20855 - Gaithersburg 20877- Gaithersburg 20878 - Gaithersburg 20879 - Garrett Park 20896 - Kensington 20895 - Montgomery Village 20886 - Olney 20830 - Olney 20832 - Potomac 20854 - Potomac 20859 - Rockville 20850 - Rockville 20852 - Rockville 20853 - Silver Spring 20903 - Silver Spring 20905 - Silver Spring 20906 - Silver Spring 20910 - Takoma Park 20912 - Wheaton 20902

    Washington DC:
    Crestwood 20011- North Capitol Hill 20002 - Cathedral Heights 20016 - American University Park 20016 - Columbia Heights 20010 - Mount Pleasant 20010 - Downtown 20036 - Dupont Circle 20009 - Logan Circle 20005- Adams Morgan 20009 - Chevy Chase 20015 - Georgetown 20007 - Cleveland Park 20008 - Foggy Bottom 20037 - Rock Creek Park - Woodley Park 20008 - Tenleytown 20016

    Northern Virginia:
    McLean 22101- McLean 22102 - McLean 22106 - Great Falls 22066 - Arlington 22201 - Arlington 22202 - Arlington 22203 - Arlington 22205 - Falls Church 22041 - Vienna 22181 - Alexandria 22314