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Riverbend Counseling Group │Riverbend Integrative Trauma Treatment

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Outpatient Therapy Request

Client's First Name*

Client's Last Name*

Email*

Phone*

Client's Date of Birth*

Month

Day

Year

Briefly, what is bringing the client into services?*

If the client a minor, are there any ongoing or upcoming court or custody issues? Is there any current or pending DSS involvement? If not applicable, please enter N/A*

If this referral is not for you, please list your name and relationship to the client or enter N/A (We can only accept referrals from legal guardians. We cannot accept referrals on behalf of adult children, spouses, friends or family members.)

Type of Insurance/Funding*

Aetna Commercial

Aetna Better Health Medicaid

Anthem Commercial

Anthem Healthkeepers Medicaid

Humana Healthy Horizons Medicaid

Sentara Commercial

Sentara Medicaid

Self Pay

CSA/FAPT Funding

Session Preference*

In-Person

Telehealth

Once your form has been submitted, the RITT Intake Coordinator will contact you. If you haven't received a response within 48 hours, please check your spam folder. The email will be coming from RITT Intake.

Please note that afterschool and evening appointments are rarely available. Your flexibility in scheduling is appreciated.

172 S. Pantops Drive, Suite C, Charlottesville, VA 22911

434.961.2555 Fax 434.961.2556

intake@riverbendcounseling.com

Locations also in Richmond and Culpeper

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