Health Insurance Option
    Please answer all of the questions below to schedule your appointment.  
    Once you submit the form, someone from our office will call you to
    confirm the day and time of your appointment.  We thank you for your
    patience.

                       All information is kept secure and confidential.   
Thank you for choosing Rio Grande Counseling & Guidance Services
Client Name (as written on the Insurance Card):
Parent(s) or Guardian(s) Name (if applicable):
Client Mailing Address
Primary contact telephone?
Other contact phones (cell, work)?
What is the best time of the day to call you to
confirm your appointment?
Health Insurance Information
Primary Insurance Company that you use?
Are you insured by any other insurance company?
"Member number (subscriber identification)" on your
insurance card?
"Group Number" on your insurance card?  
To further verify your insurance information, we will need the following:  
Client Date-Of-Birth?
Social Security Number (Optional)
Do you require special accommodations for a
disability or any special cultural needs?
No special needs are required
Yes, I require special accomodations--please explain
below
What are the three best days of the week that are good
for you to have your first appointment us?
(click on the days below...it's ok to click more than one)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What are the three best times in the day or evening
that are good for you to have your first appointment
us?
(click on the times below...use the "Ctrl" key on
your keyboard to select more than one time)
Please tell us why you want to see us?
(It's ok to click on more than one)
I feel depressed
Challenges with my child (children)
I feel very anxious
High Stress
Problems with Alcohol
Interested in seeing a doctor for my
challenges
Problems with Drugs
Marriage - Relationship
Problems
Other.  Please explain briefly.
Please tell us how you heard of us?
    Please click on the "Schedule My Appointment" button below to
    submit your appointment information.  
    We will contact you by telephone to confirm your appointment day
    and time.
Thank you for choosing Rio Grande Counseling & Guidance Services