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Roots-Raices Bilingual Counseling

Servicios en Español e Inglés

Call or Text: (501) 382-1816

New Client Paperwork

New Client Intake

Thank you for taking this step. Completing this secure form ahead of time helps your first session focus on you, not paperwork.

Before You Begin

What You'll Need

The form below takes most clients about 10–15 minutes to complete. Having a few things on hand makes it quicker:

Contact Information: Your phone number, email, and preferred way to be reached.

Emergency Contact: Name and phone number for someone we can reach if needed.

Insurance Information (if applicable): Insurance provider and member ID, if you plan to request a superbill.

A Few Minutes of Quiet: You can save and return to the form, but a quiet moment helps it go smoothly.

Complete Your Intake Form

This form is hosted securely and handled in accordance with HIPAA.

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🔒 Your information is encrypted and only accessible to your care team.

Trouble with the form?

Call or text us directly and we’ll help you complete it, or send you an alternate way to share your information.