Next Appointment Request [RC]

Follow-Up Request

Please complete this form to schedule your next appointment / follow-up visit.
Scheduling for the first time? Get started with our new client appointment request.

Our team will respond to your inquiry during business hours.
Are you the client?*
Name of Requester*

First NameLast Name
Relationship to Client*
Provider, Caregiver, Teacher, Guidance Counselor, etc.
Requesting Organization*
Hospital, Facility, School, Independent Clinic, etc. –– if you are a Caregiver, Parent, etc., please write "N/A" here.
Requester's Email*
Please enter your email address where we can contact you regarding this appointment request, as needed.
Client Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile Number*
Does the client agree to receive SMS messages at this phone number?

Yes, client agrees.
Scheduling Information

Please select your availability for efficient scheduling. Evening and weekend requests are considered special requests and will be accommodated according to the clinician's schedule.
Clinician Name*
Client's Availability
Preferred Time of Day

Morning – 8 to 11 a.m.Lunch Hour – 11 a.m. to 1 p.m.Afternoon – 1 to 5 p.m.Evening – After 5 p.m.Other
Would you like to add any other information?
Billing Information
Would you like to make an update to payment type or insurance details?*

No, I don't have any updates.Yes, I would like to update it now.Yes, please contact me for updates before my visit.
Payment Type*
Choose Insurance or Self-Pay
Insurance Provider*
Other Provider*
If selected 'Other', include the name of the Client's Insurance Provider
Member ID/EAP Auth. #*
Policy Holder's Relationship to Client*
Policy Holder's Gender*
Insurance Card (Front)
Insurance Card (Back)
Date

MonthDayYear
Today's Date
Signature

Clear
Should be Empty:

Follow-Up Request

Client Information

Scheduling Information

Billing Information