2020 Rise Counseling Group Appointment Request Form
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Email *
Full 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? *
If you answered yes to the previous question, please explain.
Please select the insurance provider you you. 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 Number
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. *
Are you requesting online services? You must be a resident of Tennessee or Ohio to request online services.
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By filling our 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- the following therapists are accepting clients. You can view the therapist profiles at: https://risecounselinggroup.com/about/ *
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? *
How did you hear about us? *
Questions/ concerns:
Please direct any questions/ concerns to hello@risecounselinggroup.com.
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