Rise Counseling Group Appointment Request Form
Due to the upcoming holiday season and increased demand, we are temporarily unable to schedule new clients. We plan to resume new client scheduling in January 2025. In the meantime, please feel free to explore our website for helpful resources or reach out with any questions. We look forward to connecting with you in the new year.
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Email *
First name:
*
Last name:
*
Client full/legal name (if different):
Client Date of Birth: *
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/
DD
/
YYYY
Phone number:
*
Briefly describe your concerns:
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Type of service requested: *
Required
Will you need services provided in another language? *
Do you have any ongoing legal concerns that will require case management? This includes court ordered services, child custody cases, divorce etc. *
If you answered yes or maybe to the previous question, please explain.
Please select the insurance provider you use. You may opt out of using your insurance as well. Next to each company, you will see which providers are eligible to bill in-network. We recommend contacting your insurance company before scheduling an appointment to verify in-network eligibility and any out of pocket costs.
*
Required
If you selected other, please type your insurance provider below. Please note: We do not currently accept Medicare or any Medicare plans. We are no longer accepting Cigna or Tricare insurances.
Member ID # located on the front of your insurance card and/or EAP Authorization # *
Client relationship to insurance subscriber:
Clear selection
Location Preference:
*
Required
What days work best for you? Please select all that apply. (We will try to accommodate your preferred day/time)
*
Required
What time of day works best for you? Please select all that apply. (We will try to accommodate your preferred day/time) *
Required
By filling out this form, you understand that your provider must be licensed to practice in the state where you are physically located when services are provided. Please select the state in which you are physically residing: *
Therapist Preference - Please select your top 3 choices. You can view therapist profiles at: https://risecounselinggroup.com/about/
(Clinicians not listed are unable to accept new clients.)
*
Required
If a therapist and time range you selected are available, are you comfortable with us scheduling the next available appointment and emailing you the online paperwork directly (you will also receive a text confirmation)?
*
How did you hear about us? *
By filling out this form, you will be subscribed to our mailing list. Only De'Asia Thompson (owner) has access to this list. It is used to send out information about groups, closures, and other important announcements for the practice. We will not spam you or use your information in an improper manner. You are free to unsubscribe at anytime. *
Questions/ concerns:
Please direct any questions/ concerns to hello@risecounselinggroup.com.
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