New Client Form
Information for new client
What is your name?
What location would you like services?
What is your phone number?
What is your physical address?
What is your birthday?
What type of insurance do you have? (Those currently accepted By Jill Janecke or Jae Csongradi are listed below.)
Wellmark Blue Cross and Blue Shield
Avera Health Plans
KEPRO (DakotaCare EAP) (Jill Janecke ONLY)
EAP Avera (Jill Janecke ONLY)
What is your insurance card member ID (Required if you are using insurance)?
Do you have a clinician preference?
Jill Janecke, MS, LPC-MH (Insurance Option) -Currently not accepting client - optional wait list
Jae Csongradi, MSW, LSW (Insurance Option)
Holly Garrett, MS (Reduced Fee Option Only and VA Referrals)
Carl Johnson, MA-Intern (Reduce Fee Option Only)
Insurance Based Clinician
Cash Option Clinician
Briefly explain your need to help us identify the best clinician for you.
Are you having suicidal thoughts?
Yes, I have a plan.
Yes I have thoughts, but do not have a plan.
No, I do not have suicidal thoughts.
Best way to contact you:
Either Email or Phone Call
How did you hear about us?
Family, Friends or Community Members
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This form was created inside of Rising Hope Counseling, LLC.