Rise Counseling Group's Appointment Request Form
Please complete the form below and we will call or email you based on your preference within 1-2 business days. Please take a look at our website to view our staff. New additions to our staff will be posted soon.

 If you are requesting appointments for multiple clients (e.g. yourself and a child), please complete a separate form for each new client. This ensures we have all the necessary details to provide the best care. After submitting a form, refresh the page to complete another.
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. 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)
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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 telehealth services are provided. Please select the state in which you are physically residing: *
Therapist Preference - To help us best match you with a therapist, please review our team at: https://risecounselinggroup.com/about/ and select your preferred clinician(s). You may select all that apply.

Please note that not all clinicians may be available to accept new clients at this time. While we will do our best to schedule you with your preferred therapist, someone else on our team may have sooner availability.

 *
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.
A copy of your responses will be emailed to the address you provided.
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