Rising Hope Counseling and Wellness                 Pre-Consultation/Waitlist Survey
Thank you so much for contacting us.   Please take a few minutes to answer the questions to be placed on our waitlist.  Please note that all therapy sessions are virtual and our hours are:

8:00am-6:00pm Tuesday
10:00am-6:00pm Wednesday
8:00am-6:00pm Thursday

We use this waitlist to fill available openings for individual therapy and group therapy.   If a therapy appointment becomes available, we use the information you provided to contact you. Below are some resources for you to help you in your therapy search as you wait for an opening here at Rising Hope.

We maintain an up-to-date Resource Page that includes referrals to other therapists who specialize in similar demographics and concerns. You’ll also find support groups and additional services that may be a good fit for what you're looking for. We encourage you to take a look, you might find the right next step or added support there.


We wish you luck and hope to partner with you on your journey.
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Name *
Date of Birth *
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DD
/
YYYY
Phone number *
E-mail *
How did you find us? (Check all that apply) *
Required
If your above answers were a referral from a friend/colleague, doctor/medical office, or other please share their name.
Will you be self pay, using insurance or FSA/HSA?
 *
Required
Which Insurance *
Seeking Services for  *
Required
Would you be interested in upcoming group support programs? 
What are your best hopes for participating in therapy services? *
Reason for Seeking Services *
Do you have reliable internet and a private, confidential place to talk during our virtual meetings? *
Which State will you be in at the time of our sessions? *
Have you been seen by a mental health professional before? If so, what was the reason for seeking services and dates you sought services with them?  *
When is your preferred availability to meet for services? (Preferred days and times) *
Reminder preference of appointment:
 *
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