Opt-Out Form for Communications Consent

Communication Opt - Out Form

Purpose: Use this form if you wish to withdraw your consent to receive communications from Rooted Therapy Center.

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

Parent/Caregiver Information

Parent/Caregiver Name(Required)

Child’s Name(Required)

Email Address(Required)

Phone Number(Required)

Withdrawal of Communication Consent (Opt-Out)

Please select the type(s) of communication you no longer wish to receive from Rooted Therapy Center:

Withdrawal of Communication Consent (Opt-Out)(Required)

All communication - I wish to withdraw my consent for all communication from Rooted Therapy Center, including phone calls, emails, and text (SMS) messages.

Phone calls - I wish to withdraw my consent for communication via phone calls.

Email - I wish to withdraw my consent for communication via email.

Text messages (SMS) - I wish to withdraw my consent for communication via text (SMS) messages.

Effect of Withdrawal

Upon submission, you will no longer receive communications from Rooted Therapy Center (except as required by law or for previously scheduled appointments).

Electronic Signature

By signing below, I confirm that I am the authorized parent or caregiver and wish to withdraw communication consent.

Signature(Required)

Date(Required)

Client Reviews

Jessica Fladger

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

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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!!