Brief Request Form

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* This field is required

Date

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4

Phone* This field is required

Area Code

Phone Number

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5

E-mail* This field is required

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6

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

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7

Type of service requested* This field is required

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8

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

YESNO

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9

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

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10

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

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11

Insurer (If applicable)

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12

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

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13

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

Afternoon

Evening

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14

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

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