Health Insurance Option
Please answer all
the questions below to schedule your
Once you submit the form, someone from our office
will call you to
confirm the day and time of
We thank you for your
All information is kept secure and confidential.
Thank you for choosing Rio Grande Counseling & Guidance Service
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
"Group Number" on your insurance card?
To further verify your insurance information, we will need the following:
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
What are the
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)
What are the
in the day or evening
that are good for you to have your first appointment
(click on the times below...use the
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
Problems with Alcohol
Interested in seeing a doctor for my
Problems with Drugs
Marriage - Relationship
Other. Please explain briefly.
Please tell us how you heard of us?
Please click on the
"Schedule My Appointment"
button below to
We will contact you by telephone to confirm your appointment
Thank you for choosing Rio Grande Counseling & Guidance Services