Opt In Form
Opt In Form

Opt - In Form

Communication Opt - In Form

Purpose: This form collects your consent to receive communications from Rooted Therapy Center regarding
your inquiries, appointments, and services via phone, email, and text (SMS).

This field is for validation purposes and should be left unchanged.

Parent/Caregiver Information

Parent/Caregiver Name(Required)
Child’s Name(Required)

Communication Preferences (Opt - In)

Please indicate how you would like to be contacted (check all that apply):
(Required)

Consent Statement

By checking any of the boxes above, I consent to receive communications from Rooted Therapy Center regarding my inquiry, scheduling, and services.

Message and data rates may apply. Standard carrier rates may apply for SMS.

You may opt out of SMS messages at any time by replying STOP. For phone or email communications, you may request to unsubscribe at any time.

Acknowledgment of Policies

I have read and agree to the Rooted Therapy Center Privacy Policy and Terms and Conditions, including the SMS communication section.(Required)
I understand all communication is handled in accordance with HIPAA privacy standards.(Required)

Electronic Signature

Clear Signature
MM slash DD slash YYYY

Client Reviews

Jessica Fladger

My son benefited greatly from working with Darra. His confidence,... Read More

Lindsey Beras

Darra and her team have been instrumental in helping my... Read More

L C

1323 years ago

Darra is the best! Highly recommend.

Spero Drosis

Highly recommend!

Chris Cassidy

Great place!! Highly recommend

Josh Mrozowsky

Darra is absolutely fantastic!!

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