Our commitment to providing High quality services often limits therapist availability

If you are interested in learning more about starting services

complete the following form and we will be In contact

We aim to initiate services within based your level of need, but the wait time is also influenced by:

Desired Office Location Flexibility with Scheduling Request for Specific Therapist

Therapeutic Modalities In Person vs. Telehealth

We do not keep a practice wide waitlist nor do we manage therapist schedules; it may take several days to determine if a therapist is both a good match for your identified needs and also accepting new clients. If we are unable to connect you with a therapist within our practice we will provide a list of other therapist you can contact for services.

Please know we are unable to provide information regarding other therapist ability to accept new clients.

We appreciate your understanding in this matter.

Service Inquiry

This form is not sent directly to a member of our clinical staff. If you are experiencing a mental health emergency call 988 or 911. Typical response time is within 5 business days.

Reason for Contact

If you are inquiring about services for someone other than yourself are they aware you have contacted us?

Note: If you are contacting for any adult we cannot schedule any services without direct contact for them. Legal documentation may be required in certain situations.

Individual Completing the Form

First Name

Last Name

Your Phone

(###)

###

####

Your Email

***PLEASE NOTE, IF YOUR CARRIER IS NOT LISTED, WE ARE NOT CREDENTIALED WITH THAT PROVIDER AND THEREFORE YOU WOULD BE CONSIDERED SELF-PAY. ***RTC IS NOT A MEDICAID, MEDICARE, BLUE OPTION, OR ANY OTHER SUPPLEMENTAL MEDICARE PLAN PROVIDER

I understand Ridgeline does not accept Medicaid, Medicare or any of the Supplementary Plans

I would like to receive a list of providers that accept Medicaid, Medicare or Supplement

Please select your insurance carrier from provided list.

.

Birthdate of Individual Seeking Services

MM

DD

YYYY

What Is Your Preferred Location?

If you feel comfortable, share a little bit of information regarding why you are seeking services

Preferred Contact Method

Phone

Email

Electronic Signature (type name)

Professional and Third Party Referrals

Download form by clicking HERE and fax to 828.604.9014 or email to Referrals@ridgelinetc.com

Without the client’s signature on the referral sheet we cannot communicate with referral source regarding status.

If you have specific or additional questions, you can email referrals@ridgelinetc.com or call (828) 307-3087.

*Please note, voicemails are not checked daily.