Therapy Enrollment Form

Therapy Enrollment Form

Welcome to Rivers of Healing! Please fill out this form to inquire about mental health therapy services. Your information will help us understand your needs and how we can assist you.
Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What state do you live in?
Insurance Member ID Number
Upload your State ID and Insurance Card for your file and for a Copay Estimate.

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Upload your State ID and Insurance Card for your file and for a Copay Estimate.

Cancelof
Monday: Select available time ranges for sessions

Morning (8am-12pm)Afternoon (12pm-4pm)Evening (4pm-8pm)Other
Tuesday: Select available time ranges for sessions

Morning (8am-12pm)Afternoon (12pm-4pm)Evening (4pm-8pm)Other
Wednesday: Select available time ranges for sessions

Morning (8am-12pm)Afternoon (12pm-4pm)Evening (4pm-8pm)Other
Thursday: Select available time ranges for sessions

Morning (8am-12pm)Afternoon (12pm-4pm)Evening (4pm-8pm)Other
Friday: Select available time ranges for sessions

Morning (8am-12pm)Afternoon (12pm-4pm)Evening (4pm-8pm)Other
Saturday: Select available time ranges for sessions

Morning (8am-12pm)Afternoon (12pm-4pm)Evening (4pm-8pm)Other
Sunday: Select available time ranges for sessions

Morning (8am-12pm)Afternoon (12pm-4pm)Evening (4pm-8pm)Other
Types of services offered

Individual therapyFamily therapyGroup therapyChild/Teen therapyPre-Marital CounselingCouples TherapyOther
What is your insurance carrier?
How did you hear about us?
Do you need a phone consultation?

YesNo
Select the days you are available for a phone consultation within the next 3 to 5 business days

MondayTuesdayWednesdayThursdayFriday
Select the time ranges you are available for a phone consultation

Morning (8am-12pm)Afternoon (12pm-4pm)Evening (4pm-8pm)
Why are you seeking mental health therapy? Please describe your concerns and goals.*
Need any of the following? (FMLA and Reasonable Accommodation Requests are not being completed at this time. Please consult your Primary Care Physician for further assistance).

Court Documents/Court Ordered ServicesADHD EvaluationsBariatric Readiness EvalsOther
Thank you for contacting Rivers of Healing to begin your therapy journey! The information your provided will help us gain clarity regarding your needs, get a copay estimate from your insurance and set up your account in our portal, "Ensora". If you would like to proceed with getting started please click "Submit Inquiry".
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