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 another language?
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.
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.
Krystin Morris, LSW (waitlist)
Jessica Jenkins, LISW (available July 27th)
Elena Moore, LSW (waitlist)
Joy Wilenbrink-Conte, MA, BC-MT, Individual/ Group Music Therapy
Marah Eagy, LSW
Dr. Shreya Bhandari, LSW
Dawn Martin, CMHC-T (Counseling Intern w/ reduced rates $45 per session) (waitlist)
Megan Cerney, LSW (Available Aug 2020)
JaNay Bankston, LSW (Available Mid July)
Vanna Thuston, LCSW-S (TX residents, Available August 2020)
Felita Anane, LCSW (NY residents, Available August 2020)
How did you hear about us?
Therapy for Black Girls
My insurance website/ EAP
Word of Mouth
Rise Counseling Group Website
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This form was created inside of De'Asia L. Thompson, LISW LLC.