We are here for you.

Person completing the form

First Name

Last Name

Is the client a minor? *

Yes

No

Client's name (if a minor):

First Name

Last Name

Phone *

(###)

###

####

Do you prefer in-person or virtual sessions? *

In-person

Virtual

Either/I'm Flexible

Would you be interested in meeting with our nurse practitioner for medication management?

Yes

Not at this time

If there is not a clinician available, would you be open to meeting with a clinical intern?

Yes

Not at this time

I have questions before answering

Would you like to learn more about our group therapy options?

Yes

Not at this time

Would you like to join our mailing list with upcoming workshops, therapeutic groups, and events? *

Yes

Not at this time

How did you hear about us? *

Psychology Today

Word of Mouth

Doctor/Pediatrician/Psychiatrist, etc.

Google

Other

I am submitting this form on my own behalf or on behalf of my client/patient and I confirm that the individual seeking services consents to being contacted by phone, email, and text by Rooted Counseling Services *

I agree