Client Portal - Rising Up, LLC

New Clients Only

If you are a current or prior client with our clinic, please log in to the client portal OR contact our staff directly. If you are a new client, please complete the information below, and we will reach out to you shortly.

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Please select a Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

If you are experiencing a life threatening emergency, do not wait for a clinician to respond to your request. Report immediately to your nearest emergency room, or call 911

Insurance:

Insurance Company Name:

Member #:

Group #:

Coinsurance (%):

Copay:

Submit

Cancel

New Clients Only

Personal Information

Contact Information

Phone

Address

Please Select a Provider:

Please explain the reason you are seeking help at this time:

Insurance