Therapy Interest Form – Arise Psychological Wellness & Consulting

Fields marked with * are required

First Name *

Last Name *

Your Email *

Phone Number *

Age *

What state do you currently live in? *

How did you hear about us? *

We often have most of our availability in our clinical education program. Are you open to being seen by a provider-in-training under the close supervision of a licensed psychologist? *

How do you plan to pay for services? (please check all options that you are open to) *

Self-pay
Out-of-network benefits
BCBS State Health Plan (SHP)
BCBS PPO
Aetna PPO
Reduced rate with training provider

Are there aspects of your identity that are important for us to know about? (some examples may include gender identity, sexual orientation, ethnoracial, or cultural identity factors)

Have you experienced severe stressors or traumatic events that have impacted your well-being? *

Please briefly describe current difficulties or issues that you're hoping to receive help with *