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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/Caregiver'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 12:00 pm - 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-F 9-2; Madison's Schedule: Mondays 9 am-5 pm, Wednesdays 5:30-7:30 pm, Saturdays 9 am-2 pm; (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 (commercial and Hoosier Health Medicaid), UMR, Aetna. Self-pay ($160 intake/$130 for 53-minute session).

Play Therapy

Sand Tray Therapy

EMDR Therapy (Stacey Only)

EMDR Intensive (Stacey Only)

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

Brainspotting (Tulsi Only)

Therapy with Stacey (children and adults)

Therapy with Tulsi (teens/adults)

Therapy with Madison (child therapist)

Briefly explain reason for seeking therapy.

Today's Date

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Request an Appointment

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Client Information

Date and Time Preference

About Your Appointment

Emergency Assistance

Reviving the Roots Counseling & Wellness