Brief Request Form

1

Full Name* This field is required

First Name

Last Name

Press
Enter

2

Client name (If different)

First Name

Last Name

Press
Enter

3

Client Date of Birth* This field is required

Date

Press
Enter

4

Phone* This field is required

Area Code

Phone Number

Press
Enter

5

E-mail* This field is required

Press
Enter

6

Primary Concern* This field is requiredWhat is bringing you in?

Small
Normal
Large
Huge

Press
Enter

7

Type of service requested* This field is required

Press
Enter

8

Do you have any legal concerns that will require any ongoing case management?* This field is requiredThis may include divorce, custody issues, children services involvement, mandated treatment

YESNO

Press
Enter

9

If you answered yes to the previous question, please briefly explain:

Small
Normal
Large
Huge

Press
Enter

10

Clinician PreferenceWhile we will do our best, there is no guarantee of assignment to this clinician.

All therapists are trained and supervised to provide excellent care.

Press
Enter

11

Insurer* This field is required

Press
Enter

12

If you selected other for your insurance type, please list it below:

Press
Enter

13

Member ID or EAP Authorization

We will verify your benefits so you know what/if you have a cost associated with your treatment

Press
Enter

14

Client relationship to subscriber:

Press
Enter

15

What days work best for you?* This field is requiredThere is no guarantee your preference is currently available, but we will try to accommodate your preference.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Press
Enter

16

What time works best for you?* This field is requiredThere 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

Press
Enter

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!* This field is required

Yes

No

Press
Enter