Schedule an Appointment

If you are interested in scheduling an initial appointment with Riss Counseling, please complete the following and submit it to us. Required fields are indicated with a red asterisk (*). You will hear from us within 2 business days.

Thank you for your interest in Riss Counseling.

Date *

Month

Day

Year

Name *

Please enter your firstname lastname

Address *

City *

State *

Zip *

Phone *

Please enter the phone number where you can best be reached.

Age *

Date of Birth *

Referred By

Were you referred to me? If so, by whom?

Reason for Seeking Counseling

Please enter your reason for seeking counseling.

Email *

Name of Insurer *

Please enter the name of your primary insurer. I accept most insurance, however I do not take Aetna or Cigna. I see United Behavioral Health/United Healthcare out of network only.

Member # / ID # *

Please enter your insurance member or ID number.

Group # *

Please enter your insurer's group number.

Insurer Phone Number *

Please enter your insurer's phone number in the form (xxx) xxx-xxxx.

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