• 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.
  • Demographic Information

    Tell us about yourself
  • Demographic Information

    Tell us about yourself
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    Pick a Date
  • Financially Responsible Party (FRP)

  •  - -
    Pick a Date
  • Requested Services

  • Insurance Information

    Please provide your insurance information as this will expedite the intake process.
  • (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.

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  • Additional insurance information:

  • Communication Preferences

    How should we reach you?
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