New Client Interest Form

New Client Interest Form

Thank you for your interest in scheduling an appointment with Sunrise Counseling & Psychological Services!
We are accepting new clients at this time!

Confidentiality: The information collected on this form will be used in the client’s best interests to be scheduled to receive psychological/medication services. The information provided will be handled in a professional and confidential manner. Sunrise Counseling holds the disclosure of confidential Information in confidence and will not release any disclosed information to any third party or entity without prior written consent.
Please verify that you are human*

Demographic Information

Tell us about yourself
Please select from the following:*

I am seeking services for myself.I am a parent/guardian seeking services for a minor.

Demographic Information

Tell us about yourself
Client's Name: (Legal)*

First NameLast Name
Client's Preferred name or nickname:
Client's Date of birth:*

MonthDayYear
Date
Client's Sex: (Legal)*

MaleFemale
Client's Gender Identity:

MaleFemaleTrans man (FTM)Trans woman (MTF)Non-binaryOther

Financially Responsible Party (FRP)
Responsible Party Name:*

First NameLast Name
Responsible Party Date of birth:*

MonthDayYear
Date
Responsible Party Sex: (Legal)*

MaleFemale
Responsible Party Gender Identity:

MaleFemaleTrans man (FTM)Trans woman (MTF)Non-binaryOther
Responsible Party Contact Phone Number:*
Responsible Party Contact email:*
Responsible Party Home Address:*

Requested Services
What services are you interested in? (Choose all that apply)*

Medication ManagementTherapyPsychological Testing and AssessmentsSpeech Therapy
If you have a request for a specific provider, type of service, or would like to provide any additional details about the services you are requesting, please do so here:

Insurance Information

Please provide your insurance information as this will expedite the intake process.
For your services, do you have insurance or would you be Self-Pay?*

InsuranceSelf-Pay
Insurance Provider:*
Member ID/Policy Number:*
(For Tricare members, please provide your " Benefits # ")

Need help? The benefits number can be found on the back of your DOD ID in the upper-lefthand corner.
(OR: Upload a photo of your insurance card):

Browse Files

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Additional insurance information:
Additional policy information/details if available:
If you are Tricare Prime with a referral to Sunrise Counseling, Please include your referral information below:

We are accepting new clients at this time!