First Name

Last Name

Email Address

Phone Number

I'm interested in: I'm interested in: Nutritional Counseling Mental Health Counseling Both

Why nutritional counseling?

Why mental health counseling?

Why both?

Please indicate your availability for appointments: Please indicate your availability for appointments: Morning: 9am - 12pm Mid-day: 12pm - 3pm Afternoon: 3pm - 5pm I am flexible with scheduling

Is your preference to meet in person or virtually? Is your preference to meet in person or virtually? In Person Virtually Either In Person or Virtual Sessions will work

Will you be paying via insurance or self-pay? Will you be paying via insurance or self-pay? Insurance Self-Pay

What is your insurance plan?

Your State Your StateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

How did you hear about New Roots? How did you hear about New Roots? A friend or family member A medical professional A mental health provider The internet Other