New Client Interest Form
Thank you for your interest in scheduling an appointment with Sunrise Counseling & Psychological Services!
WE ARE ACCEPTING NEW CLIENTS! Please continue filling out this form to provide us some more information on how we can help you!
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
Tell us about yourself
Client's Preferred name or nickname:
Client's Date of birth:
If you are seeking services on behalf of a minor, please state your name and your relationship:
Contact Phone Number:
What services are you interested in? (Choose all that apply)
Psychological Testing and Assessments
Medical Marijuana Card
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:
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?
Member ID/Policy Number:
(OR: Upload a photo of your insurance card):
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:
How should we reach you?
Please choose all that apply:
Should be Empty: