New Client Information Form
Visit our website here: 


Insurances Accepted: 
Cigna
Health Alliance HMO/PPO
HealthPartners
HealthSmart PPO (Interplan)​
Humana ChoiceCare PPO & HMO Commercial
Interplan Health Group PPO
Medical Associates Health Plans -- with referral & authorization from your doctor/PCP.
Midlands Choice PPO
Medicare
MMC Tiered Network 
O'Hara Workers Compensation
TRICARE West / Health Net Federal Services (TRICARE) 
Wellmark HMO & Wellmark PPO
*If your insurance is not on this list, please look into your insurance's "out-of-network (OON)" coverage.*

View our team here:  https://www.risecounselingandconsulting.com/our-team 

Please fill out this form to get started! 
Once received, we will email you to schedule (watch your spam/junk folder!). 
Sign in to Google to save your progress. Learn more
Email *
Phone Number *
Name of person who will be receiving services *
DOB of person who will be receiving services *
MM
/
DD
/
YYYY
What type of insurance(s) do you have?
Please list ALL insurances you have, even the ones we don't take (Medicaid, etc.).
We can bill United Healthcare out-of-network (OON), please check your UHC OON benefit coverage.
 *
What services are you seeking?  *
Required
Why are you seeking services? What do you want to work on in therapy or what are you seeking medication for?  *
What is your appointment availability? 
Please be specific and provide as many options as possible. 
Our typical office hours are Monday-Thursday 8AM-5PM but some providers may have limited availability outside of that!
 *
Do you prefer in person or virtual sessions?
(Please note, client receiving services must reside in Iowa and be in Iowa at time of session.) *
Required
How did you hear about RISE Counseling?
(From a Current Client, Friend, Facebook, Newspaper, School, Doctor, Google, etc.) *
Are you wanting to work with a specific provider at RISE?
If so, please list their name. *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of RISE Counseling & Consulting, PLLC. Report Abuse
Google Forms