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.
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CLIENT INFORMATION
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INSURANCE INFORMATION
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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.
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