Dr. Chalice C. Rhodes, Licensed Professional Counselor, LLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Are you located in Georgia, Florida, Delaware or New Jersey?

Of these insurances which one do you have: Evernorth/Cigna, Oxford/Oscar/Optum/United Healthcare, Aetna, AmeriHealth, Independence Blue Cross Blue Shield, Ascension (Smart Health), Carelon Behavioral Health, Anthem Blue Cross and Blue Shield of Georgia, and Quest Behavioral Health, and Horizon Blue Cross and Blue Shield of New Jersey.

I understand that my eligibility for services will be determined based on my physical location and the type of service requested.

I agree

If applicable, are you located outside of the USA states of Georgia, Florida, Delaware or New Jersey?

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.