Release and Renew Mental Wellness
Compassionate, culturally responsive mental health care for children, adolescents, and adults. Move beyond survival and into emotional clarity
New Client/Patient Pre-Intake Form
Compassionate Mental Health Care for Children, Adolescents, & Adults
Thank you for your interest in Release and Renew Mental Wellness. Our practice provides comprehensive psychiatric evaluation, medication management, therapy, and integrative mental health services.
To begin the process of becoming a client/patient, please complete the pre-intake form below. This information helps our team determine the most appropriate services and provider for your needs.
Once your request is received, our team will review your submission and follow up within 1-2 business days regarding scheduling and next steps.
After submitting this form:
Our team will review your information.
If appropriate for care, you will receive instructions via your preferred method listed in the form to schedule a New Patient Intake Appointment.
Additional intake paperwork may be sent through the client/patient portal once you are accepted.
Please allow 1–2 business days for review.
Our Services
Mental Health Services
At Release & Renew Mental Wellness, we provide comprehensive, whole-person mental health care for children, teens, and adults. Our services blend evidence-based psychiatry, compassionate therapy, and integrative wellness to support emotional balance, mental clarity, and overall well-being.
Our Locations
- Maryland
- Delaware
- Florida
- Connecticut
- Tennessee
- Washington DC (Coming Soon)
Wondering if we accept your insurance or treat your specific condition?
Simply click below for details.
Insurances Accepted
Private Pay / Out-of-Network Options
If we are not in-network with your insurance, we offer:
Affordable self-pay rates
Sliding fee scale (when eligible)
Superbills for out-of-network reimbursement
FSA/HSA acceptance
Privacy Notice
Client Portal
Access all your care in one secure place. Use the client portal to schedule appointments, send messages, request refills, update insurance, complete forms, and pay your bills. Everything you need for your care is organized here for your convenience
New Client/Patient Pre-Intake Form
Contact Us
We offer a personalized experience for every client. Please share your inquiry below, and one of our team members will respond within 1-2 business days to help you get started with the support you need.
Your wellness is our priority!
- contact@releaserenewmentalwellness.com
- (410) 376-8728
- 1301 York Road Suite 800 Lutherville Timonium, MD 21093
-
Monda to Friday 9am to 5pm
Saturday — Sunday
Crisis Resources
Testimonials
When I was in a crisis, knowing I could call 988 immediately gave me a sense of safety. The support felt real, calm, and non-judgmental
Policies & Patient Rights
Telehealth Policy
(Meets MD, DE, FL, CT, TN, and DC Telehealth Requirements)
Release & Renew Mental Wellness, LLC**
Overview
We provide HIPAA-compliant telehealth services to clients located in:
Maryland
Delaware
Florida
Connecticut
Tennessee
Washington, DC
Clients must be physically located within one of these states at the time of the appointment.
Technology Requirements
Telehealth sessions are conducted through encrypted platforms. Clients must have:
Reliable internet connection
A private, confidential space
A device with camera and audio
We may reschedule if privacy cannot be assured.
Informed Consent for Telehealth
Before receiving telehealth services, clients must provide:
Verbal or written telehealth consent
Identification verification
Emergency location information for each session
Limitations of Telehealth
Telehealth may not be appropriate for:
Emergencies or crisis situations requiring immediate intervention
Clients without access to private or secure communication
Certain assessments requiring physical presence
If telehealth becomes clinically inappropriate, an in-person referral will be recommended.
Confidentiality
We maintain the same privacy standards as in-person care. Clients agree not to:
Record sessions
Allow unauthorized individuals to overhear sessions
We do not record telehealth sessions under any circumstances.
Emergency Protocols
Clients must provide:
Current physical location each session
Emergency contact
Local emergency service information
If safety concerns arise, appropriate emergency steps will be taken.
Cross-State Regulations
Surpassing federal telemedicine laws, we comply with:
MD Telehealth Act
DE Telemedicine Regulations
FL Telehealth Provider Registration requirements
CT Behavioral Health Telehealth Statutes
TN Telehealth Modernization Act
DC Telehealth Coverage Act
Notice of Privacy Practices (NPP) — HIPAA-required
Release & Renew Mental Wellness, LLC
Effective Date: January 1, 2025
This Notice of Privacy Practices describes how medical and mental health information about you may be used and disclosed and how you can access this information. Please review it carefully.
If you have any questions, please contact us at:
admin@releaserenewmentalwellness.com
Your Privacy Rights
You have the right to:
1. Get an Electronic or Paper Copy of Your Medical Record
You may ask to see or get a copy of your mental health record.
We will provide a copy or summary within 30 days, for a reasonable fee.
Certain psychotherapy notes require a separate authorization.
2. Ask Us to Correct Your Record
If you believe information is incomplete or incorrect, you may request a correction.
We may deny requests in certain circumstances but will explain our reasoning in writing.
3. Request Confidential Communication
You may request that we contact you at a different location, phone number, or via secure portal.
4. Ask Us to Limit What We Use or Share
You may request restrictions on the use or disclosure of your information.
We are not required to agree to all restrictions, but if we do agree, we will comply unless disclosure is required by law.
5. Get a List of Disclosures
You may request an accounting of disclosures made in the past six years, excluding:
Treatment
Payment
Healthcare operations
6. Get a Copy of This Notice
You may request a digital or paper copy of this NPP at any time.
7. Choose Someone to Act for You
If you have a legal guardian, Power of Attorney, or healthcare proxy, we will verify their authority before sharing your information.
8. File a Complaint
You may file a complaint if you believe your privacy rights have been violated, with:
Release & Renew Mental Wellness
Email: admin@releaserenewmw.com
or
Office for Civil Rights
U.S. Department of Health & Human Services
www.hhs.gov/ocr/privacy
We will not retaliate against you for filing a complaint.
Patient Rights & Responsibilities
Effective: January 1, 2025
Your Rights
As a client of Release & Renew Mental Wellness, you have the right to:
Be treated with dignity, respect, and cultural sensitivity
Receive services free of discrimination
Participate in your treatment plan
Ask questions and obtain clear explanations of care
Request reasonable accommodations
Decline or withdraw from treatment at any time
Access your records as permitted by law
Confidentiality of your PHI
Submit grievances or complaints without retaliation
Receive timely responses to scheduling, billing, and administrative concerns
Your Responsibilities
For care to be effective and compliant, clients agree to:
Scheduling & Attendance
Maintain consistent attendance at scheduled appointments
Provide 24-hour notice for cancellations
Understand that no more than 4 no-shows or late cancellations are allowed within a 12-month period
Understand that exceeding the limit may result in discharge from care
Financial Responsibilities
Pay copayments, coinsurance, deductibles, and balances when due
Maintain valid insurance information at all times
Notify the office immediately when:
Insurance changes
Coverage ends
A new card is issued
Ensure Coordination of Benefits (COB) is current and on file
Understand that no more than 2 missed copayments are permitted
Exceeding this may result in restricted scheduling or discharge
Clinical Engagement
Provide accurate and honest information
Participate actively in treatment recommendations
Maintain a safe and respectful environment with staff
Self-Pay Fee Disclosure
Effective: January 1, 2025
Release & Renew Mental Wellness follows transparent self-pay pricing as required by federal and state law.
Self-Pay Clients Are Responsible For:
Full session fees at the time of service
Fees for ESA letters, FMLA forms, and other documentation
Fees for missed appointments or late cancellations
Services not covered by insurance
Self-Pay Services Include (examples):
ESA letters
FMLA paperwork
Bariatric evaluations
Emotional or behavioral assessments
Therapy or medication appointments (if not using insurance)
Payment Methods
We accept debit/credit cards and HSA/FSA (where applicable).
Good Faith Estimate (No Surprises Act)
Effective: January 1, 2025
(No Surprises Act Compliance)
Under federal law, you have the right to receive a Good Faith Estimate explaining the expected cost of non-emergency services if you:
Are uninsured
Choose not to use insurance
Request self-pay pricing
Your Good Faith Estimate Will Include:
Expected number of sessions
Estimated total cost of treatment
Any additional administrative fees related to self-pay services
This is an estimate only, not a contract or guarantee.
To request a Good Faith Estimate:
Email: admin@releaserenewmentalwellness.com
Cancellation & No-Show Policy
Effective: January 1, 2025
To protect provider time and ensure access to care, the following policies apply:
Cancellation Requirements
Clients must cancel or reschedule at least 24 hours before the appointment.
Cancellations made with less than 24 hours may be charged a $75 late cancellation fee.
No-Show Policy
A no-show occurs when:
The client does not attend the appointment
The client arrives more than 10 minutes late
The client cannot be seen due to incomplete forms or missing insurance information
Limit:
No more than 4 no-shows or late cancellations in a 12-month period.
Exceeding this limit may result in discharge from the practice.
Missed Copayments
Clients must pay copays on the day of service.
Limit:
No more than 2 missed copayments within a 12-month period.
Failure to meet this requirement may result in:
Suspension of scheduling
Required payment before booking future appointments
Possible discharge
Insurance Requirements
Clients are responsible for:
Keeping insurance information updated
Notifying the office immediately of changes
Ensuring Coordination of Benefits (COB) is on file
Understanding that incorrect or outdated insurance may result in:
Claim denials
Fee for No-Show or Late Cancellation
The standard fee is $75.
Insurance does not cover missed appointment fees.
🚨 If you are in crisis, call or text 988 or dial 911 immediately.
Release and Renew Mental Wellness does not provide 24-hour emergency services.
Client/Patient Portal, SMS, and email are not monitored for emergencies.
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Contact Us
- contact@releaserenewmentalwellness.com
- (410) 376-8728
- 1301 York Road Suite 800 Lutherville Timonium, MD 21093
-
Monda to Friday 9am to 5pm
Saturday — Sunday
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