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Rise Counseling Group Appointment Request
We just need a little bit of info from you and we will be in touch shortly!
17
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1
Full Name
*
This field is required
First Name
Last Name
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2
Client name (If different)
First Name
Last Name
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3
Client Date of Birth
*
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Date
Year
Month
Day
Date
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4
Phone
*
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Area Code
Phone Number
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5
E-mail
*
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6
Primary Concern
*
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What is bringing you in?
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7
Type of service requested
*
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Individual Therapy
Group Therapy
Family Therapy
Couples Therapy
Immigration Evaluation
Individual Therapy
Group Therapy
Family Therapy
Couples Therapy
Immigration Evaluation
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8
Do you have any legal concerns that will require any ongoing case management?
*
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This may include divorce, custody issues, children services involvement, mandated treatment
YES
NO
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9
If you answered yes to the previous question, please briefly explain:
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10
Clinician Preference
While we will do our best, there is no guarantee of assignment to this clinician.
Despina Costandinidis, LISW
Kelly Browning, LSW
Karen Micka, LPCC
No preference
Despina Costandinidis, LISW
Kelly Browning, LSW
Karen Micka, LPCC
No preference
All therapists are trained and supervised to provide excellent care.
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11
Insurer
*
This field is required
Aetna
Anthem BCBS
CareSource
Medical Mutual
TriCare
United Healthcare/ UMR
Other
Impact EAP
TriHealth EAP
Ceridian/Lifeworks EAP
Reach EAP
Health Advocate EAP
No insurance/ private pay
Aetna
Anthem BCBS
CareSource
Medical Mutual
TriCare
United Healthcare/ UMR
Other
Impact EAP
TriHealth EAP
Ceridian/Lifeworks EAP
Reach EAP
Health Advocate EAP
No insurance/ private pay
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12
If you selected other for your insurance type, please list it below:
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13
Member ID or EAP Authorization
We will verify your benefits so you know what/if you have a cost associated with your treatment
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14
Client relationship to subscriber:
Self
Spouse
Child
Other
Self
Spouse
Child
Other
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15
What days work best for you?
*
This field is required
There is no guarantee your preference is currently available, but we will try to accommodate your preference.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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16
What time works best for you?
*
This field is required
There is no guarantee your preference is currently available, but we will try to accommodate your preference.
Morning 9-12
Afternoon 12-4
Evening 4-8
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17
I would like to be added to Rise Counseling Group's newsletter/ blog list services. Please note that we do not rent or sell your information to any third parties!
*
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Yes
No
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