Current/ Returning Client Intake Request

If you are experience a psychiatric emergency, do not complete this form.

Instead, please call 9-1-1 or your local Community Services Board crisis hotline or go to your nearest emergency department. These forms are not reviewed immediately and RCC does not provide crisis services.

Please complete this form so we may assist you in receiving additional or re-establishing services!

Have you been seen by a clinician at RCC after June 2022?

Yes No

Do you currently have access to your InSync Healthcare Patient Portal? The patient portal can be accessed at https://richmondcreativeintouch.insynchcs.com/

Yes No

Would you prefer we follow up with you via patient portal messaging or via telephone call?

Portal Messaging Phone Call No Preference

Client Information

Full name

Is this request for a minor child?

Yes No

Legal Guardian(s) Name(s)

Is your contact information the same as listed in our system currently?

Yes- please use the phone number on file! No/ I'm not sure

Let us call you!

If we are unable to reach you, would you like us to leave you a voicemail?

Yes, please leave a message No, please do NOT leave a message

If we are unable to reach you, where can we send a follow up email?

About Your Request

Which service(s) are you seeking? Please select all that apply

Individual Therapy

Couples Therapy

Family Therapy

Group Therapy

Medication Management

Psychological Testing

Registered Dietitian

GCS Letter Writing (Ari Laoch)

Are you currently receiving services at RCC?

Yes No

Are you seeking additional services or are you looking to change providers?

Additional Services I want a new provider

Please note: it is our policy to consult with your current clinician before scheduling an intake with a new clinician so as to ensure appropriate clinical transition is facilitated!

Please identify your current provider(s).

Do you have a preference for clinician(s) you'd like to see?

Please note: this does not guarantee you will be scheduled with your preferred clinician(s).

Insurance Information

Do we have your current insurance information?

Yes- nothing has changed No/ I'm not sure N/A- I will not be using insurance

At Richmond Creative Counseling, our providers are unable to accept Medicare, Aetna Better Health of Virginia Medicaid, or Virginia Premier Medicaid.
Unfortunately, at this time none of our PMHNPs can accept Tricare for Medication Management appointments.
Failure to provide accurate insurance information may result in patient accepting full financial responsibility. It is recommended you contact your insurance company to verify your outpatient mental health benefits.

I have read and understand the above statements.

Acknowledged

Please enter insurance information.

Please upload a copy of the front and back of your insurance card. If using Medicaid, please upload BOTH your Medicaid and MCO cards.

Add file

Please upload a file

Do you have any form of Medicare? Including supplemental or Part B

Yes No

It is important to RCC that all of our clients are able to receive ethical, unbiased, and confidential care. It is for that reason that we ask the following questions:

Do you have a current or past relationship, personal or professional, with any staff at RCC?

Yes No

Are you related to any staff at RCC?

Yes No

Please indicate with whom and the nature of your relationship, past or present.

Our patient registration coordinator will give you a call as soon as possible! Please ensure that your phone is able to receive voicemails so that if we miss you, we are able to leave a message. All calls will come from the phone number (804) 592-6311. We look forward to speaking with you!

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