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CapitolHill Consortium for Counseling & Consultation, LLC

REFERRAL FORM

Office: (240) 920-6834 Fax: (240) 920-6832 Email: m.leptic@ccccmentalhealth.com

If this is an emergency, please dial 911, or dial 988, or go to your nearest emergency room.

Please fill out this referral form if you would like to obtain services from Dr. Michael Leptic, Licensed Psychology Associate with CapitolHill Consortium for Counseling & Consultation, LLC. (MD License: A0946 Expires: 3/31/2026)


At this time, Dr. Leptic only offers virtual services in Maryland.

Date of Referral

Patient Information

Birthdate
Gender identity
Pronouns
Marital status

Insurance Information

When would you like to start services?

Services Needed

Mental Health Information

Are you exhibiting any of the following symptoms?

Additional Documents (If applicable)

Please upload any relevant documentation including medical records or supplemental information. (Not required)

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