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Emergency Assistance

If this is an emergency, call:

Crisis Line: 866-903-3787
Call: 988

Client Information

First name

Last name

Email address

Phone number

Age

Parent's Name (if request is for a minor)

I'm already a client

Date and Time Preference

Not all listed days/times are currently available

Stacey's Schedule: Mondays 12:00 pm - 5:00 pm, Tuesdays 10:00 am - 5:00 pm, Wednesdays 9:00 am - 4:00 pm, Thursdays 8:00 am - 4:00 pm, (Fridays and Saturdays - EMDR Intensives Only) Tulsi's Schedule: M 9-5, T 9-2, W 9-2, Th 9-2, F 9-5 (PLEASE NOTE NOT ALL TIMES ARE CURRENTLY AVAILABLE.)

About Your Appointment

Reason for Visit (Check all that apply)

Individual Therapy

In-network with commercial Anthem BCBS (non-Medicaid/HMO), Optum, United Healthcare, UMR, Aetna. Self-pay ($150 intake/$120 for 53-minute session).

Play Therapy ( Stacey Only)

In-network with commercial Anthem BCBS (non-Medicaid/HMO), Optum, United Healthcare, UMR, Aetna. Self-pay ($150 intake/$120 for 53-minute session).

EMDR Therapy (Stacey Only)

In-network with commercial Anthem BCBS (non-Medicaid/HMO), Optum, United Healthcare, UMR, Aetna. Self-pay ($150 intake/$120 for 53-minute session).

EMDR Intensive (Stacey Only)

Insurance can be billed for the first 53 minutes, then self-pay each additional hour (only on Fridays and Saturdays)

Therapy with Stacey

Therapy with Tulsi

Sand Tray Therapy (Stacey Only)

Briefly explain reason for seeking therapy.

Today's Date

How Did You Hear About Reviving The Roots Counseling?

i.e. Who referred you? Internet Search?

Preferred Method of Contact

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Request an Appointment

Emergency Assistance

Client Information

Date and Time Preference

About Your Appointment

Emergency Assistance

Reviving The Roots Counseling, LLC