Old Georgetown Mental Health Associates
301-897-0099
  • About OGMHA
  • Location & Contact Information
  • Hours/Scheduling/Prescriptions
  • Patient Forms
  • Payment / Insurance
  • Sylwia Fowler, MD
  • Miriam Galescu, MD
  • C. Lawrence Horn, MD
  • Daniel Kauffman, MD
  • Daniel Levine, MD
  • Amy Motamed, DO
  • Tolulope Omojokun, MD
  • Andrew D. Peters, DO

Patient Forms

​Completed forms may be brought into the office for your appointment or faxed to our office at 301-897-8537. When faxing, please reference your specific doctor. When you arrive for your initial appointment, please check in with the receptionist

Completion of these forms prior to your first appointment will save you time in the waiting room:
  • Registration Sheet
  • Policies and Procedures
Completion of these forms will provide information that will be helpful during your initial consultation:
  • DSM-5 Symptom Measure
  • Medical Symptom Checklist (Review of Systems)
  • Medication History
  • Sleepiness Scale
Please print this for your reference:
  • Notice of Privacy Policies (HIPAA)
These additional forms may be requested by your doctor:
  • Release of Information
  • PHQ-9
  • GAD-7
  • HCL-32
  • Depression Scale CUDOS-18​
  • Binge Eating Disorder Checklist
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Phone: 301-897-0099 | Extensions: Fowler-310 Galescu-312 Kauffman-303 Levine-304 Motamed-301 Omojokun-305 Peters-313
  Horn: 240-242-9856

Portal: https://ogmhaintouch.insynchcs.com/

Practice Manager: La Shawn Farrish 301-897-0099 ext. 300| Fax: 301-897-8537
10215 Fernwood Road, Suite 520, Bethesda, MD 20817