Home Adults Alcohol and Drugs Our Staff Contact Us Directions Payment Options Online Appointment Home Adults Alcohol and Drugs Our Staff Contact Us Directions Payment Options Online Appointment Health Insurance Option Please answer all of the questions below to schedule your appointment. Once you submit the form, someone from our office will call you to confirm the day and time of your appointment. We thank you for your patience. All information is kept secure and confidentialThank you for choosing Rio Grande Counseling & Guidance ServicesYour Name (as written on the Insurance Card, please) Parent(s) or Guardian(s) Name (if applicable) Your Residence Address Your Mailing Address (for correspondence) Primary Contact Telephone?Other contact phones (cell, work)?Email Address What is the best time of the day to call you to confirm your appointment? Health Insurance Information Primary Insurance Company that you use? Primary "Member ID" on your insurance card? Primary "Group Number" on your insurance card? Are you insured by any other insurance company (Secondary Insurance)? Secondary Member ID on your insurance card? (if applicable) Secondary Group Number on your insurance card? (if applicable ) To further verify your insurance information, we will need the following: Your Date-Of-Birth (optional for now)We need your date of birth to verify your identify and to verify your insurance coverage. Month Day Year Do you require special accommodations for a disability or any special cultural needs? No special needs are required Yes, I require special accomodations If yes, Please Explain Below(Optional) We serve a diverse community and want to do a better job at serving the community. Please list any other information that you would like us to know about you (such as race, ethnicity, nationality, biological sex, gender identity, sexual orientation, gender expression, preferred name(s), preferred pronouns, etc.)What are the three best days of the week that are good for you to have your first appointment us?(click on the days below...it's ok to click more than one) Monday Tuesday Wednesday Thursday Friday Saturday Sunday What are the three best times in the day or evening that are good for you to have your first appointment us?(click on the times below...it's ok to click more than one) 8:00 a.m. 9:00 a.m. 10:00 a.m. 11:00 a.m. 12:00 p.m. 1:00 p.m. 2:00 p.m. 3:00 p.m. 4:00 p.m. 5:00 p.m. 6:00 p.m. 7:00 p.m. Please tell us why you want to see us?(It's ok to click on more than one) I feel depressed I feel very anxious Problems with Alcohol Problems with Drugs Marriage - Relationship Problems Challenges with my child (children) High Stress Interested in seeing a doctor for my challenges Other Have you been recently discharged from any hospital? Yes No Name of Hospital Date of Discharge Please Explain BrieflyPlease tell us how you heard of us?Please click on the "Schedule My Appointment" button below to submit your appointment information. We will contact you by telephone to confirm your appointment day and time.CAPTCHA Thank you for choosing Rio Grande Counseling & Guidance Services