Therapy Request Form
Please provide us with the following information to initiate services. 
IF YOU PLAN TO USE INSURANCE: Please gather all your information to submit in this form to speed the process up. Any questions can be sent to therapy@rhombuscounseling.com. A team member will contact you to follow up within the next 5 business days. This form is encrypted for security.

Please check our website for a list of our therapists at www.rhombuscounseling.com

If you are looking for court mandated groups, please fill this form out instead:
https://forms.gle/dFWHxXZUvdbKoGhZA
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Client's First & Last Name *
Client Phone number *
Physical Address with ZIP CODE (for emergency purposes. ) *
Client's email address *
Client's Date of Birth *
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Age of Client  *
Contact Person (if different than above) *
Type of Therapy *
Required
Therapy Preference *
If you prefer in-person therapy, which office location do you prefer? *
Do you have a particular therapist you would like to see?
Why are you seeking therapy? *
How are you paying for services provided *
If you plan to use insurance, please include these items found on your insurance card. Missing information may slow down the process. Write the information on the line below:
Please use the space below to fill out the 4 pieces of insurance information that we are requesting.
Current Insurance Providers:
If you are seeking couple or family therapy, please fill out the following information: Please list first and last names, dates of birth, addresses, phone numbers, email addresses and any additional insurance that others in the group may be carrying.  
How do you identify?
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How did you hear about us? *
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