Rise Together Consultation Request

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Please enter the following information and our administrator will reach out to you as soon as possible.

What is your name and pronouns? *

What is a good phone number to reach you at? (optional)

Please describe briefly what brings you in for therapy. (Describe as much or as little as you feel comfortable)

Do you have any preferences of your future therapist? (gender, identification, age, specialty)

What is your availability for a weekly counseling session? *

Are you interested in virtual sessions or in person sessions? *

Telehealth

In-Person

No preference, virtual or in person sessions are fine

Please enter an email we can best reach you at *

What is your birthdate?

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Would you like to receive an email updates regarding our wellness activities? *

Yes

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