Rise Counseling Group Appointment Request Form
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Email *
First Name *
Last Name *
Client full name (if different)
Client Date of Birth *
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DD
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Phone number (xxx)xxx-xxxx *
Primary Concern *
Type of service requested *
Required
Will you need services provided in another language?
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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. If you don't want to or aren't able to use your insurance with a specific provider, you can use Out of Network benefits with the provider of your choice. This may or may not change the cost for your services. *
Required
If you selected other, please type your insurance plan below. Please note we do not accept Paramount, Buckeye Health, Molina, United Healthcare Community Plan, Aetna Better Health (medicare/medicaid), or medicare.
Member ID # located on the front of your insurance card and/or EAP Authorization #
Client relationship to subscriber
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What days work best for you? *
Required
What time of day works best for you? *
Required
By filling out this form, you understand that all services are conducted via telehealth only and that you must physically residing in Ohio to request services. *
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. *
Therapist Preference - You can view therapist profiles at: https://risecounselinggroup.com/about/ (Please note that due to a recent influx in requests caused by the ongoing pandemic, most therapists have an active waiting list at this time.) *
Required
If the therapist and time range you selected are available, are you comfortable with us scheduling the next available appointment and emailing you the paperwork directly? *
How did you hear about us? *
Questions/ concerns:
Please direct any questions/ concerns to hello@risecounselinggroup.com.
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