Name *

First Name

Last Name

Phone Number *

(###)

###

####

Date of Birth *

MM

DD

YYYY

RISE MHC is currently only offering virtual appointments. Are you comfortable with engaging in therapy virtually? *

Yes

No

Are you currently located in PA, DE, NJ, or FL? *

Our providers are licensed in some of the following states: Pennsylvania, New Jersey, Delaware, and Florida. Please visit the "Our Therapists" page for more details about which therapist is licensed in your state.

Pennsylvania

New Jersey

Florida

Delaware

Daily Availability *

Check all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Time Availbility *

Check all that apply

Morning (7am-10am)

Late Morning (10am-12pm)

Afternoon (12pm-2pm)

Late Afternoon (2pm-4pm)

Early Evening (4pm-6pm)

Evening (6pm-8pm)

INSURANCE DISCLAIMER *

By clicking submit, I understand that RISE Mental Health Collective is not in a network with any insurance providers. If you wish to get reimbursed, your therapist will work with you to help you submit out-of-network super bills. RISE Mental Health Collective also accepts HSA or FSA cards in addition to all other forms of payment.

I Agree