NEW SERVICES REQUEST FORM

Request for Services

This form allows you to request information or services from RTG Clinic. Please provide only the information reasonably necessary for us to understand your request and contact you.

Submitting this form does not guarantee acceptance as a client, confirm that a requested service is available, schedule an appointment, or establish a therapist-client or other professional relationship. A professional relationship is established only after RTG Clinic confirms acceptance and completes its required intake and consent process with you.

Privacy and Security Notice

RTG Clinic uses Wix to host this website and securely collect form submissions. Wix acts as a technology service provider supporting the collection, transmission, and storage of information submitted through this form.

RTG Clinic has activated Wix’s protected-health-information safeguards for this website. Information submitted through this form will be handled in accordance with applicable privacy and security requirements, RTG Clinic’s privacy practices, and Wix’s supported security controls.

Although RTG Clinic uses reasonable administrative, technical, and physical safeguards, no internet-based system can be guaranteed to be completely free from risk. Please do not submit information beyond what is requested or reasonably necessary for us to respond.

How We Will Use Your Information

RTG Clinic will use the information submitted through this form to:

• Review and respond to your request for services.

• Determine whether RTG Clinic may be able to meet your needs.

• Contact you using the communication methods you authorize.

• Conduct preliminary insurance benefits & eligibility verification.

• Direct your request to an appropriate authorized staff member.

• Maintain administrative records related to your inquiry.

• Provide referrals or alternative resources when appropriate.

  
  

Your information will not be used for unrelated marketing purposes without your permission. Access will be limited to authorized personnel who reasonably need the information to evaluate or respond to your request.

RTG Clinic may use or disclose information when permitted or required by law, including for treatment, payment, healthcare operations, safety, public-health, reporting, or legal obligations, as applicable.

Permission to Contact You

By submitting this form, you authorize RTG Clinic to contact you regarding your request using the telephone number, email address, or other contact information you provide.

This Form Is Not for Emergencies

This form is not continuously monitored and should not be used for emergencies, urgent safety concerns, crisis intervention, or time-sensitive clinical needs.

If you or someone else may be in immediate danger, call 911 or go to the nearest emergency department. In the United States, you may also call or text 988 to reach the Suicide & Crisis Lifeline.

Do not use this form to report an emergency or request an immediate clinical response.

Submission Acknowledgement

I have read and understand the notices above. I understand the purpose for which my information is being collected, that submitting this form does not establish a professional relationship or guarantee services, and that this form must not be used for emergencies. I authorize RTG Clinic to use the information I provide to evaluate and respond to my request and to contact me according to the preferences I selected.