Referral | Rise Counseling and Wellness Group

How did you hear about us?

Client's Full Name

DOB required

Street Address

Client or Parent Email Address

School & Grade (if applicable)

Parent/Guardian Full Name (if client is under 18 years old)

Phone Number

Reason for referral

Availability for sessions: Required

Mornings

Afternoons (12-4p)

Evenings (4-8p)

Other

Availability for sessions: Required

Virtual

In person (Hagerstown)

If an in person provider is not available, I am willing to do virtual sessions.

Availability details

Member ID #

If Self-Pay/Out of Network: I agree to the self pay rates:

Initial Evaluation: $180

53-60 minute individual session: $140

45 minute individual session: $115

45 minute family/couple's session: $130

We appreciate the referral & will be in touch soon! Contact admin@risecounselingllc.com for questions/concerns

301-778-5900