Rum River Counseling, Inc. Appointment Request Form

Note: If you are experiencing a medical emergency please dial 911 to contact local emergency response personnel.

Please be assured that this online appointment request is a secured and confidential area and that information entered and submitted is confidential.

You may also contact us by phone.
Twin Cities area: (763) 482-9598
Brainerd area: (218) 838-9812

Attention: If you are not the intended client, please be sure to fill this form out with the appropriate client information.

How did you hear about us?
New or returning client?	*	New Client Returning Client
Preferred Office Location:	*
Did you have a particular therapist in mind?
Please list reason for visit or symptoms for visit.

CLIENT INFORMATION
Client First Name:	*
Client Last Name:	*
Client Birthdate (mm/dd/yyyy):	*
Client Gender:	*	Male Female
Address:	*
City, State:
Zip:	*
Phone Number (include area code):	*
Email Address:	*

INSURANCE INFORMATION
Insurance Name:	*
Insurance ID#:
Insurance Group #:
Insurance Subscriber (the person who carries this insurance):
Subscriber Birthdate (mm/dd/yyyy):
Subscriber place of Employment:
Date insurance started, if known (mm/dd/yyyy):
Is there a secondary insurance policy?		No Yes
Are you familiar with your benefit coverage?		Yes No (Please contact your insurance company for coverage information.)

CONTACT INFORMATION
You will be contacted by our scheduling coordinator to review additional medical and financial information, including insurance coverage, before an appointment is offered. Please provide contact information below.
Scheduling Contact Person:
Best Phone Number to Call:
Best Time to Call:
May we leave a message?		Yes No
Alternative Contact Phone Number:
Best Time to Call:
May we leave a message?		Yes No
If you would like to provide additional information to the scheduling coordinator, please type it here:
Security Code	*