Appointment Request

Name *

First Name

Last Name

Phone *

(###)

###

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Desired Counseling *

Individual Counseling

Couple's Counseling

Child Counseling

Adolescent Counseling

Protected Health Information *

Any contact with Rise Counseling Treasure Coast is optional and does not constitute a client-therapist relationship. Regardless of Rise Counseling's attempts to keep your information secure, there are inherent risks to electronic communication and we cannot guarantee that such communication won’t be lost, delayed, intercepted, corrupted or otherwise altered, rendered incomplete, or fail to be delivered. By using this form, you are authorizing Rise Counseling Treasure Coast, LLC and its representatives to communicate electronically directly with you about what may be your protected health information and are assuming all responsibility and liability for any breach of confidentiality. You agree to fully release and hold harmless Rise Counseling Treasure Coast, LLC and its representatives from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with protected health information.

I have read and understand the above statement

Non Emergency Acknowledgement *

The purpose of this contact form is for general questions and inquiries. Rise Counseling Treasure Coast is not equipped to respond to medical or mental health emergencies. By using this form, you are acknowledging the limitations of Rise Counseling Treasure Coast, LLC to assist with a medical emergency or mental health crisis, and assuming all responsibility and liability for any medical emergency or mental health crisis you may be experiencing. If you are experiencing a medical emergency or mental health crisis, dial 911 or 988.

I have read and understand the above statement