You can always press Enter⏎ to continue

Dayton PD Rum River Counseling Appointment Registration Form

Note: If you are experiencing a medical emergency please dial 911 to contact local emergency response personnel. This form is not to be used in the event of a crisis or emergency.
37Questions
  • 1

    NOTE:

    We do not get involved with disability determination, custody studies, or handle any and all legal or court related issues. We do not provide prescriptive letters for emotional support animals and we do not complete disability and/or FMLA paperwork.

    Press
    Enter
  • 2
    If you are not, then you will be directed to our standard Appointment Registration form.
    Press
    Enter
  • 3

    Before you begin completing this form, please be sure that you have your insurance card available, if you plan to use insurance to pay for your services. 

    Also, if you are unable to finish this form completely, there is an option to save the form so that you can finish it at another time. (Note: this feature may not work on all browsers or all mobile devices.)

    Mobile view:

    Desktop view:

    Press
    Enter
  • 4
    Clients turning 18 - please check the New Client option.
    Press
    Enter
  • 5
    Select any that apply. **It is very important that you reply right away once an appointment is offered as we do not reserve the appointment for you until you confirm your commitment.**
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    If you are a returning client, please indicate if there is a therapist you wish to return to, Keep in mind that we strive to find the therapist who is the best fit for you. If you do not feel that the therapist is the right fit, you can always let us know by completing the Current Client Internal Referral form on the Current Client tab of our website.
    Press
    Enter
  • 8
    While most of our providers are seeing clients in person, teletherapy will always continue to be an ongoing option for our clients with all therapists. Please let us know which office location(s) work best for you. Please check all that apply.
    Press
    Enter
  • 9
    • Huge
    • Large
    • Normal
    • Small
    Ok
    quoteCreated with Sketch.
    Ok
    Press
    Enter
  • 10
    List all Rum River Counseling therapists that you have received services from:
    Press
    Enter
  • 11
    List all Rum River Counseling office locations that you have received services from:
    Press
    Enter
  • 12
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    (Please tell us your legal gender as indicated with your insurance company.)
    Press
    Enter
  • 15
    Press
    Enter
  • 16
    -
    Pick a Date
    Press
    Enter
  • 17
    Please Select
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 18
    Please select the options for appointment reminders and enter the email address and/or phone number where you prefer to receive automated appointment reminders.
    • Text
    • Phone/Voicemail
    • Email
    Press
    Enter
  • 19
    If there is an emergency with you in our building or in session, we will call 911 and request an ambulance. We will also call the emergency contact person that you list below. Also, if we do not hear from you after a no show missed appointment and have serious for concerns regarding your safety, we may reach out to your identified emergency contact.
    Press
    Enter
  • 20
    Continuity and coordination between physical and mental health is an important aspect in the delivery of quality health care, as mental and physical disorders can interact to affect an individual’s health. Insurance companies require the patient to complete the PCP Release form. To authorize release of information to providers, other than the PCP, please complete a general release form: ‘Authorization to Release Information.’ Please check one of the following:
    Press
    Enter
  • 21
    Contact Info
    Press
    Enter
  • 22
    I, the undersigned client/client legal guardian, authorize the exchange of information regarding my clinical care needed to coordinate treatment with my primary care provider. I understand that my records are protected under the Federal and specific State confidentiality laws and regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g., the provision of treatment upon consent to disclose third party payers) and that this consent expires automatically as described below. Information to be released includes diagnosis, treatment procedures and details of my condition which help to coordinate treatment. I further acknowledge that the information to be released was fully explained to me and this consent is given of my own free will. This release is valid for 1 year after last contact and I may cancel it in writing at any time
    Press
    Enter
  • 23
    Press
    Enter
  • 24
    Press
    Enter
  • 25
    If you select YES, you will be redirected to complete a Release of Information upon completion of the Appointment Registration form.
    Press
    Enter
  • 26
    If client is a minor, a copy of the legal guardian's ID is required.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 27
    Please open or download and review as you will be required to sign that you agree to the terms of this document.
    Press
    Enter
  • 28
    I, the undersigned client/client legal guardian(s), acknowledge that I am consenting to treatment/services at Rum River Counseling, Inc. and have been provided with a copy of, and that I fully understand & agree to all of the terms and conditions of the Counseling Policies, including the Notice of Privacy Practices (HIPAA).If I have questions, the information has been explained and/or summarized for me.
    Press
    Enter
  • 29

    We require a MINIMUM of 24-hour advance notice for appointment cancellations to avoid a charge. Our late cancellation fee is $100 and the no-show fee is $150. It’s important to remember that insurance will not pay for missed appointments, so you will be responsible for the full fee, not just a copay. It is up to your therapist’s discretion to require more than 24-hour notice or to charge a higher rate for missed appointments. You are responsible for appointments you schedule whether you receive automated reminders or not.

    This cancellation policy is important for a counseling practice because, while a medical doctor can see 30+ patients in a day, your therapist generally sees a maximum of 6 or 7. Your therapist reserves this time specifically for you (a full hour of time for the session and clinical notes). If you cancel with less than a full 24-hour notice, they won’t be able to fill that time slot, and will lose an entire hour from their work schedule.

    Our cancellation policy is not a penalty or a punishment. The reality is, if you are in counseling long enough, at some point you might forget about an appointment, or something will come up in your schedule that will result in you missing an appointment. Maybe you’ll need to work late. Maybe you’ll get a sudden onset of the flu. Maybe your kids will have doctor appointments, or your car will break down, or something unavoidable will come up. In return, understand that scheduling an appointment is much like buying tickets to an event. If you miss the event, it doesn’t matter why you missed it, or even if it was your first time, you can’t turn in your tickets for a refund.

    If you are unable to make it to an in-person appointment, it might be an option to see your therapist via teletherapy. This is up to the discretion of your therapist, as some therapy modalities are best processed in person.

    Same day scheduling is an alternative if you are unable to commit to a reserved appointment time. Because we have many people who are waiting for appointments, clients who fail or cancel even one appointment without 24-hour notice risk being able to schedule ongoing reserved appointments and will be subject to the therapist’s “same day” availability. With same day scheduling, no appointment is reserved for you, and you will need to contact your therapist the morning of the day you would like to meet to see if they have any available times that day to see you.

    Successful on-going therapy requires a commitment on the part of the client. It is important that you keep your appointment if at all possible.

    Press
    Enter
  • 30
    We can only reserve appointments with clients who are committed to attending scheduled appointments and who understand and agree to the missed appointment fees if 24 hour notice is not provided. This policy is part of the terms & conditions of the Counseling Policies.
    Press
    Enter
  • 31
    Or the person completing this form on behalf of a client.
    Press
    Enter
  • 32
    Press
    Enter
  • 33
    Press
    Enter
  • 34
    Press
    Enter
  • 35
    Press
    Enter
  • 36
    Press
    Enter
  • 37
    Press
    Enter
  • Should be Empty:
Question Label
1 of 37See AllGo Back
close