Rooted Connections Therapy, LLC

Rooted Connections Therapy, LLC Send Message

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What brings you to counseling at this time?

Limited to 600 characters

Are you seeking counseling because of a court order, legal proceeding, probation requirement, custody matter, or other legal requirement?

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Are you primarily seeking treatment for alcohol or substance use concerns?

Yes No

Are you currently experiencing a mental health crisis or seeking immediate emergency support?

Yes No

Have you had thoughts of harming yourself or ending your life within the past 30 days?

Yes No

Have you been hospitalized for a mental health concern within the past 6 months?

Yes No

Billing & Payment

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning Afternoon Evening

Do you consent to the use of AI in the delivery of your care?

Your clinician may use AI tools (such as using AI to generate an intake summary) to help support your care. Your information is protected under HIPAA and anything generated by AI is always reviewed by your clinician. AI does not make decisions about your care. You can withdraw this consent at any time by contacting your provider without it impacting the care you receive.

Yes No

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.