Reigle Therapeutics Group New Service Request/Demographic Form

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Thank you for considering Reigle Therapeutics Group! Please provide the information below so we know how to best help you, and someone will be in touch shortly!

Name of Individual Services Being Requested For: *

Date of Birth: *

YYYY

Address: *

Email - providing an email address allows us to send registration information for our Client Portal, important forms to be completed when services are conducted virtually, handouts/homework throughout the course of treatment, links for virtual appointments, appointment and billing reminders!

Email Address: *

Phone Number - appointment and billing reminders will be sent to this phone number!

Phone Number: *

Insurance - please provide name of insurance and insurance member ID#. If no insurance, please indicate "self-pay". *

Please write a brief description of how RTG can help. *

Please check the service(s) you are seeking... *

Individual Therapy

Couples/Family Therapy

Required

Please check the setting(s) you prefer... *

Office Setting

Virtual Setting

Required

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