Riverside Family Support Send Message

Who would be receiving care?

Your info

For insurance verification
Select the state you live in
Please list the address affiliated with the client's insurance if applicable
Administrative
Enter how you were referred to our services
Do not upload sensitive financial information such as credit card information.
Please select all
Billing & Payment
If your insurance is not listed in the dropdown menu, we may not currently be credentialed with that plan. We are actively adding new insurances. In the meantime, we can provide therapy at our self-pay rate and offer a superbill for potential out-of-network reimbursement.
Upload a photo of your insurance card
Client Preferences
For example: what you'd like to focus on, insurance or payment questions, etc.
Limited to 600 characters
Reason for care
Sometimes courts require individuals to participate in therapy as part of a legal process. If that applies to you, please select Yes. If you are seeking services on your own, please select No.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.