Online Appointment

Rum River Counseling, Inc. Appointment Request Form

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

If there is a separation, divorce or custody agreement, the Important Signatures page of the Minor Counseling Policies must be completed & signed by the minor's parents or guardians & faxed to 612-235-6447 or scanned & emailed to office@rumrivercounseling. Our office must receive the Important Signatures page of the Minor Counseling Policies from BOTH parents prior to scheduling an intake appointment.

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 (763) 482-9598

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?
For yourself or a minor	*	Myself Minor Child
If scheduling for minor, please confirm that parents are together		Parents together Parents not together (I understand that if parents are not together, the office must receive the Important Signatures page of the Minor Counseling Policies from BOTH parents before scheduling the intake appointment.)
New or returning client?	*	New Client Returning Client
Preferred Office Location(s):	*
Do you have particular therapists in mind?	*
If you are a returning client, please indicate if there is a therapist you wish to return to.
Please share a little about why you are seeking counseling so that we may better understand your needs & situation to help determine the best fit for you.	*

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

INSURANCE INFORMATION
If you plan to use insurance coverage, you must provide ALL current insurance information.
Insurance Name:	*
Insurance Group #:
Date insurance started, if known (mm/dd/yyyy):
Insurance ID#:
Insurance Subscriber (the person who carries this insurance):
Subscriber Birthdate (mm/dd/yyyy):
Subscriber place of Employment:
Is there a secondary insurance policy?	*	No Yes
Secondary Insurance Name:
Secondary Insurance Group #:
Date secondary insurance started, if known (mm/dd/yyyy):
Secondary Insurance ID#:
Secondary Insurance Subscriber (the person who carries this insurance):
Secondary Subscriber Birthdate (mm/dd/yyyy):
Secondary Subscriber place of Employment:

CONTACT INFORMATION
We will review your information and follow up with you within 1-2 business days. We may ask you a few questions to better understand your needs and situation, to help determine which therapist is the best fit for you. We may also need to review additional information, including insurance coverage, before an appointment is offered. Please provide contact information below.
Preferred method of contact:	*	Please email me Please call me I am okay with either an email or phone call
Scheduling Contact Person:	*
Preferred Email Address to use:
Preferred Phone Number to Call:
May we leave a voice message at this phone number?		Yes No
If you would like to provide additional information to the scheduling coordinator, please type it here:
Security Code	*