Renew & Rise Service Request Form

Renew & Rise

Empowering healing and growth through Renew & Rise – proudly offered in partnership with Rise Counseling Group.
Enrolled Sister's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of Person Completing form, if not the enrolled sister

First NameLast Name
Email address
E-mail
example@example.com
Contact Number:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
A signed service agreement is required to proceed with your request. If no agreement is on file, submitting this form will redirect you to the service agreement form to complete it. Requests cannot be processed until a valid agreement is submitted.

If no date is intered in the field below, a signed contract is not on file
Date
In case of emergency
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Do you have insurance that can be billed for this service?*

YesNo
Please upload a copy of your insurance card.

Cancelof
Service

Mental Wellness
If you have insurance, we will bill your provider for this service. If you do not have insurance, My Sister’s Keeper will cover the cost of the service based on funding availability. You will be notified by My Sister’s Keeper regarding the number of sessions and the covered expenses before services begin.
Status
Approved Individual Sessions
Approved Family/Group Sessions
Cost Covered per Session
Request Notes
Should be Empty:

Renew & Rise