Secure Contact Form

Thank you for reaching out

This is a secure inquiry form for Good Roots Counseling. Once we receive your form, we will reach out within two business days regarding next steps and scheduling availability.

First name

Last name

Email address

Phone number

State of residence

Date of Birth

I give Rebecca Faggett permission to contact me via phone or email. Email is reserved for scheduling and administrative purposes only (e.g., appointment coordination, paperwork, or billing questions). Please note that I do not provide clinical support or therapeutic services via phone or email. If you are experiencing a crisis, please contact emergency services or a crisis line in your area.

Yes No

I am interesting in the following services: (Check all that apply)

Individual Therapy

Couples Therapy

Sex Therapy

EMDR/ Trauma Therapy

Speaking

Other

Who are you seeking services for?

Myself

Myself and other individual(s)

Other

If you are inquiring on behalf of another adult, please note that all adults are responsible for initiating contact and providing their own consent for services. In accordance with confidentiality and ethical guidelines, we do not initiate contact with individuals who have not personally inquired about services. While we are happy to share general information about our services and processes with anyone seeking to learn more, we are unable to discuss specific details about another party without consent, and we will not make arrangements or move forward with services unless directly contacted by the prospective client.

How did you find Rebecca? Were you referred by someone?

What brings you to therapy at this time?

Good Roots Counseling does not provide emergency or crisis services. If you are experiencing thoughts of harming yourself or others, call 911, 988, or go to your nearest emergency room.

Scheduling Availability

Good Roots Counseling, PLLC currently offers Telehealth appointments Monday through Thursday between 11:00 AM and 5:00 PM (Central Time). Please indicate the times you are generally available for appointments. While completion of this form does not guarantee scheduling availability, your responses will help determine whether our schedules may be a good fit.

Monday

11:00 AM- 1:00 PM

1:00 PM- 3:00 PM

3:00 PM- 5:00 PM

Tuesday

11:00 AM- 1:00 PM

1:00 PM- 3:00 PM

3:00 PM- 5:00 PM

Wednesday

11:00 AM- 1:00 PM

1:00 PM- 3:00 PM

3:00 PM- 5:00 PM

Thursday

11:00 AM- 1:00 PM

1:00 PM- 3:00 PM

3:00 PM- 5:00 PM

Notes on Availability

My availability varies week to week

My availability is pretty consistent

I am flexible within the available appointment times

Preferred appointment frequency: Please note that new clients typically start at weekly or biweekly rhythm

Weekly Every other week Monthly Unsure

Do you have Health Insurance? We are required by law to ask if you have insurance. Good Roots Counseling is a fee-for-service, private practice provider and does not currently participate in insurance plans.

Yes No

Are you eligible for Medicare Benefits? We are required by law to ask if you qualify for medicare. Good Roots Counseling is a fee-for-service, private practice provider and does not currently participate in filing with/for medicare.

Yes No

Verification of Information I acknowledge and grant permission to be contacted at the information listed about from Good Roots Counseling, PLLC. I agree that I have completed this form for myself. By checking 'Yes', it denotes my signature and validity to the above form.

Yes No

Telehealth Services Acknowledgement Good Roots Counseling, PLLC is a virtual therapy practice. All counseling services are provided through secure online video sessions. By checking "Yes", I acknowledge that I am interested in receiving Telehealth services and understand that additional Telehealth consent forms will be provided before services begin.

Yes No

Consent and Acknowledgment:
By signing this form, you acknowledge that the information provided is accurate to the best of your knowledge. You also consent to being contacted by Rebecca to initiate services as outlined in this form.

Rebecca Faggett uses Hushmail as a confidential, HIPAA compliant email service. You will need to login to a secure portal to view and respond to any emails. This can easily connect to your present email address.

Your information will be encrypted.