2021 Rise Counseling Group Appointment Request Form
We just need a little info from you and we will be in touch soon!
Email address *
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?
Clear selection
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. *
Required
If you selected other, please type your insurance plan below.
Member ID # 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? We will try our best to accommodate you. *
Required
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.)
Clear selection
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 most therapist profiles at: https://risecounselinggroup.com/about/ (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. *
Required
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? *
Do you prefer to be contacted by phone or email? *
How did you hear about us? *
Questions/ concerns:
Please direct any questions/ concerns to hello@risecounselinggroup.com.
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