Begin Your Journey

Patient Intake Form

Complete this form to start the intake process. A member of our clinical team will contact you within one business day. All information is encrypted and protected under HIPAA.

Personal Information

Full Legal Name *

Preferred Name

Date of Birth *

Contact Information

Primary Phone *

Email Address

Street Address

City

State

ZIP Code

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relationship

Insurance Information

Insurance Provider

Insurance ID Number

Preferences

Preferred Contact Method *

Preferred Contact Time

Clinical Information

Reason for Seeking Services *

Current Medications

Previous Mental Health Treatment

Consent

I consent to RISE MHC contacting me regarding services. I understand this form is encrypted and my information is protected under HIPAA. *

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Intake Form Submitted

Thank you for submitting your intake form. A member of our team will contact you within one business day to schedule your first appointment.