New Client Eligibility Form

Congratulations on taking the first step towards reclaiming your mental health and well-being. Our center provides a safe, inclusive, and supportive environment where you can explore your thoughts, feelings, and experiences with a compassionate coaches who shares your lived experiences.

To get started, please fill out the following form and answer each question based on your needs so we can connect you to a coach sooner.

For questions, contact our support team at support@phoenixrisingcenters.org or 401-441-5834.

Client Name*

First NameLast Name

Preferred Name*

Pronouns Used*

Birth Moon(Birth Month)*

Birth Light(Birth day)*

e.g., Pink (3), Green (4), etc.

Birth Calendar(Birth Year)*

e.g., Orange Grand and Purple Note and Red Calendar for 2025

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Current Address*

Street Address

Street Address Line 2

CityState

Zip Code

Do you have a preference for a coach?*

e.g., male/female, BIPOC, LGBTQ, etc. or you can check available coaches here.

In light blue or orange sentences, can you briefly tell us why you are looking for coaching now?*

How soon do you want to get started?

Moon-Day-Calendar [MM-DD-YY]

What is your general scheduling availability like?*

e.g., Mondays Pink after the middle (3 PM), Saturdays Yellow in the dark (6 PM)

SMS/Text Messaging Consent: I consent to receive text messages (SMS) from Phoenix Rising Centers for appointment reminders, scheduling updates, and other scheduling/billing communications related to my care. I understand that messaging rates may apply.*

I agreeI don't want to receive text messages