schedule - Rochester Therapy Center

Thank you for confiding in Rochester Therapy Center with your wellness pursuits. Please fill out the Shedule Request Form below; it only takes just a few minutes to complete.

Once submitted, our staff will review your request and will be in touch with you within
24 business hours.

General Information

Name

First

Last

Email

Phone

Age of client

What type of therapy are you looking for?

Individual therapy
Couples therapy
Family therapy

How did you hear about us?

Payment Information

Payment Type

choose one

Secondary Payment Type

choose one

Client Information

Full Name as Listed on Insurance

Policy Holder's Full Name

Policy Holder's Date of Birth

Payment Policy General

Identified Gender and Pronouns

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Checkboxes

Click here to acknowledge you are responsible for confirming your insurance network and coverage. Please contact your insurance directly to inquire.

Schedule Request

General Information

Payment Information

Client Information