2021 Rise Counseling Group Appointment Request Form
We just need a little info from you and we will be in touch soon!
Client full name (if different)
Client Date of Birth
Phone number (xxx)xxx-xxxx
Type of service requested
Couples Counseling (not typically covered by insurance)
Group Coaching- Boundaries/ Women's Group
Online Therapy (Ohio Residents)
Online Therapy (Tennessee Residents)
Mental Health Education/Speaking/Training
Will you need services provided in another language?
Do you have any ongoing legal concerns that will require case management?
If you answered yes 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.
Aetna - All therapists
Anthem - All therapists
Caresource - All therapists
Cigna - All therapists
Medical Mutual - All therapists
United Healthcare/UMR - De'Asia Thompson, LISW-S, all others can be billed the deductible rate or billed out of network
Tricare - De'Asia Thompson, all others are Out of Network (you will need a referral to see them, this may change your deductible slightly)
Open Path Collective - reduced rate of $60 per session, must complete OP application
Custom Designed Benefits - All therapists
The Loveland Foundation -- All therapists (must forward email with voucher numbers to
No Insurance (Private Pay)
Opting out of insurance (Private Pay)
Out of Network (you can receive a superbill for your services)
If you selected other, please type your insurance plan below.
Member ID # and/or EAP Authorization #
Client relationship to subscriber
What days work best for you?
What time of day works best for you? We will try our best to accommodate you.
Are you requesting online services? You must be a resident of Tennessee or Ohio to request online services. (Due to COVID-19 all services are only offered online at this time.)
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.
Yes, I understand.
Therapist Preference - You can view most therapist profiles at:
(Any therapist may have an active waiting list at any given time.) -- Thank you for your patience as we continue to update our website with new therapist bios.
De'Asia Thompson, LISW (not currently accepting new clients)
Krystin Morris, LSW (not currently accepting new clients)
Elena Moore, LSW (has an active waiting list)
Dr. Shreya Bhandari, LSW (has limited availability but is accepting new clients)
Jessica Jenkins, LSW (not currently accepting new clients)
Marah Eagy, LSW (not currently accepting new clients)
Megan Cerney, LMSW (has an active waiting list)
JaNay Bankston, LSW (may have a waiting list)
Mellaney Edwards, LSW (may have a waiting list)
Melody Arbour, LSW (currently accepting new clients)
Jessica Daniels, LPC (has limited availability but is accepting new clients)
Teri Timberlake, LSW (currently accepting new clients)
Devida Crawford, LSW (has limited availability but is accepting new clients)
Joy Willenbrink-Conte, MA, MT-CB (Groups only)
If the therapist and time range you selected are available, are you comfortable with us scheduling the next available appt. and sending you the paperwork directly?
No, please call or email me.
Do you prefer to be contacted by phone or email?
How did you hear about us?
Therapy for Black Girls
My Insurance / EAP
Word of Mouth
Rise Counseling Group Website
Please direct any questions/ concerns to
Send me a copy of my responses.
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