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 *
Your answer
Client full name (If different)
Your answer
Client Date of Birth *
MM
/
DD
/
YYYY
Phone number (xxx)xxx-xxxx *
Your answer
Primary Concern *
Your answer
Type of service requested *
Required
Will you need services provided in Arabic?
Do you have any ongoing legal concerns that will require case management? *
If you answered yes to the previous question, please explain.
Your answer
We are in Network with the following insurances/ EAPs. Please select your insurer. *
Required
If you selected other, please type your insurance plan below.
Your answer
Member ID or EAP Authorization Number
Your answer
Client relationship to subscriber
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.
I would like to be added to Rise Counseling Group's email list? Please know we do not sell or rent your information to any 3rd parties, and will not bug you with daily messages. *
How did you hear about us? *
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