First Name
*
Last Name
*
Email
*
Phone
*
How can we help? (Please limit your response to 1-3 sentences)
*
Messaging Consent
*
By providing your phone number, you agree to receive texts from Rouse Relational Wellness; message and data rates may apply, and you can reply STOP to opt out.
Insurance
*
By clicking this box, you acknowledge that we primarily accept private pay, but some EAP programs. We can offer support for out-of-network reimbursement.
Submit