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Patient's Name*

First Last

Date of Birth*

Parent Name*

First Last

(For patients that are minors; otherwise enter N/A)

Email*

Phone*

Referred By*

Why are you seeking treatment services?*

Have you/has your child participated in therapy before? If yes, when and where? How would you describe your experience?*

Do you anticipate any court/legal involvement (custody, divorce proceedings, occupational or educational proceedings, etc.)*

Is there anything else you would like for us to know?*

Frequently Asked Questions

Do we need a referral or diagnosis to begin therapy?

No, you can request treatment services on your own by clicking the “Getting Started” button on our website, and completing the “New Patient Request Form.” We will then contact you via email to discuss best options for you or your child for treatment services.

Do you work with children and adults?

Yes! We provide treatment to individuals, couples, and families! We see people of all ages for treatment, so please inquire if you are interested in services, or have questions about your specific circumstances and needs. We would love to work with you.

At what age can my child start therapy?

Any age! We are passionate about early childhood intervention and meeting needs before they develop into bigger issues – we see many toddlers, parent-infant dyads, and young kiddos for treatment, and would be more than happy to work with your child as well! Feel free to reach out with any questions you may have regarding early childhood intervention.

Do you work with insurance?

Roots is committed to providing each patient with high-quality personalized care that isn’t limited by insurance constraints, which is why our services are self-pay only. Patients do have the option to use HSA funds to cover the cost of treatment, or request treatment notes or invoices to submit charges to their insurance company for reimbursement according to policy guidelines.

Do you offer in-person or virtual services?

Both! We offer in-person outpatient, home-based, and community-based services and supports, as well as some virtual therapy services. We will work with you in determining the best course of action for your or your child’s treatment based on your level of health and comfort and treatment needs and goals to ensure that your family’s needs are met in the best way possible.

How long does treatment last?

This is something that you and your provider will determine together. As needs are different for everyone, it can be hard to put a specific timeframe to how long treatment will last for any particular individual. However, we typically re-assess needs, progress, growth, and ongoing goals every 12 sessions to determine appropriate next steps in treatment.