Request Evaluation for Eating Disorder Care

Client's First name

Client's Last name

Email

Age

Phone

What service(s) are you interested in?

Tell us more about your desired goal(s), outcome(s), or life change after working with RICERP. The more specific, the better. Answers are confidential.

What days (M-F) and times (between 8:00am and 6:00pm) are you generally available for appointments?

Please let us know who referred you to our services.

Are you filling this out for a minor under your care?

Yes

No

I understand that at this time, RICERP only accepts Blue Cross Blue Shield insurance or self-pay clients.

Request an Initial Evaluation