Name *

First Name

Last Name

If seeking support for child/youth between the ages of 12-18 - please list their name:

First Name

Last Name

Phone *

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Do you have insurance?

Please check with your provider that they cover social work services.

Yes, I have insurance

No, I am paying out of pocket

I have questions regarding insurance and payment

I am an indigenous person with status and wish to be covered by NIHB

We are able to direct bill to:

Check option that applies

Blue Cross (if your account is set up online)

NIHB

Cooporators

How'd you hear about Rise?

Social Media

Psychology Today

Website

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