Rise Counseling Group Appointment Request Form
We just need. a little info from you and we will be in touch shortly!
Client full name (If different)
Client Date of Birth
Phone number (xxx)xxx-xxxx
Type of service requested
Group Coaching- Boundaries/ Women's Group
Online Therapy (Ohio Residents)
Online Therapy (Tennessee Residents)
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.
We are in Network with the following insurances/ EAPs. Please select your insurer.
United Healthcare/ UMR
Health Advocate EAP
RiseCounseling Group EAP
Open Path Collective
Private Pay/ No Insurance
If you selected other, please type your insurance plan below.
Member ID or EAP Authorization Number
Client relationship to subscriber
What days work best for you?
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?
Psychology Today- De'Asia
Psychology Today- Despina
Therapy for Black Girls
My insurance website/ EAP
Word of Mouth
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This form was created inside of De'Asia L. Thompson, LISW LLC.