Rooted Mental Health Services

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Rooted Mental Health Services is licensed to provide care in Illinois, Idaho, and Washington. Please specify which state you are physically located in.

Illinois Idaho Washington Another State

Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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Administrative

Are you currently working with a licensed therapist, counselor, or psychologist? If so, please provide their name and clinic details below.

I love collaborating with therapists to ensure your medication plan and therapy goals are completely aligned! Please note that due to federal medical privacy laws (HIPAA), I cannot contact your provider or discuss your care until a formal Release of Information (ROI) is securely in place. If you would like us to coordinate, just let me know during our upcoming session and I will instantly drop a digital ROI form into your patient portal for a quick electronic signature.

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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.