Rise Counseling Group Appointment Request Form
We just need. a little info from you and we will be in touch shortly!
Email address *
Full Name *
Client full name (If different)
Client Date of Birth *
MM
/
DD
/
YYYY
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.
We are in Network with the following insurances/ EAPs. Please select your insurer. *
Required
If you selected other, please type your insurance plan below.
Member ID or EAP Authorization Number
Client relationship to subscriber
Clear selection
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.
Clear selection
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. *
How did you hear about us? *
Submit
Never submit passwords through Google Forms.
This form was created inside of De'Asia L. Thompson, LISW LLC. Report Abuse