New 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 the form so we may assist you in getting established with RCC!

Client Information

Full name

Primary Email Address

Is this intake request for a minor child?

Yes No

Legal Guardian(s) Name(s)

How would you like us to contact you?

Phone Call Email Secure Patient Portal

Let us call you!

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

Yes, please! No thank you; please follow up via email.

We can email you!

To request communication via our secure patient portal, please follow the link below and complete the required information. All messaging will be done through the Patient Portal.

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)

Have you previously received services from RCC?

Yes No

Please identify who you saw.

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).

Please briefly describe the presenting issue(s) for which you're requesting treatment.

If you are following a clinician from a previous practice, please enter their name below.

Insurance Information

Are you intending to use insurance for your services?

Yes No- I will be paying out of pocket

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!

Your information will be encrypted.