New Client Request for Appointment Form

384 C & 386 B Carriage House Drive
Jackson, TN 38305
731.868.7297 (phone)

877.273.4824 (fax)
info@rohcs.org

www.rohcs.org
Appointment Request Form

Please complete the form below to begin the process of receiving services.
Referral Information
Name of Person Completing Form
Referred from / Agency Name
Phone Number
Email Address
Client Demographics
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Birth Gender
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Mobile Number
Email
example@example.com
Please send us a copy of the current Parenting Plan if applicable.
Parent/Guardian Name

First NameLast Name
Relationship
Mobile Number
Email
example@example.com
Parent/Guardian Name

First NameLast Name
Relationship
Mobile Number
Email
example@example.com
Insurance Information

Please complete the below information and upload a front and back photo of your insurance card
Insurance Provider:
Subscriber Name:
Subscriber/Member ID:
Group ID:
EAP Authorization Number:
If Applicable
EAP Company:
If Applicable
Upload Front of Insurance Card
Upload Back of Insurance Card
Clinical Information
What is the reason for requesting counseling?
Please describe behaviors and/or issues with which the client is currently struggling.
Which Counselor Would You Prefer the Client See for Counseling?
Please enter your first prefered choice
Which Counselor Would You Prefer the Client See for Counseling?
Please enter your second prefered choice
Meet Our Counselors
How may we contact you moving forward regarding scheduling an appointment?

Phone/ VoicemailMailEmailSMS/TextOther
Once we verify your insurance information and check counselor availability, we will contact you to complete the intake paperwork to schedule an appointment.
We applaud you for taking a step toward improving your mental health.
Should be Empty:

Appointment Request Form

Referral Information

Client Demographics

Insurance Information

Clinical Information

Meet Our Counselors