Contact – Diverse Roots Therapy

Get in Touch

PLEASE NOTE THAT WE HAVE RECEIVED YOUR CONTACT FORM EVEN WHEN THE WEBSITE GIVES YOU AN ERROR MESSAGE! If you do not hear from us within 48 hours after filling out the form, feel free to contact us at admin@diverserootstherapy.com.

Name

Legal name (ie which name should we put on receipts/use for insurance)

Insurance info (if applicable)

Pronouns

Date of birth

Email address

Phone Number

Preferred language

Type of therapy

Location

Availability (ie Monday mornings, Tuesday evenings, etc.)

Presenting issues

How did you hear about us?

Juvonno client portal sign up/login

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