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Registration Form - Oakwood Roots RPT Consult Groups
Upon completion of this form, you will be contacted by a Roots clinician to complete your registration process. Contact Jeremy Dew, Clinical Director, for any questions at
jeremy@oakwoodroots.com
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Email
*
Your email
NAME:
Your answer
EMAIL ADDRESS:
Your answer
LICENSE TYPE, LIC# NUMBER (i.e., LPC, TX #71786, or "graduate student on LPC track")
Your answer
THERAPEUTIC ORIENTATION/APPROACH:
Your answer
YEARS IN PRACTICE:
Your answer
WHAT IS YOUR HOPE IN CHOOSING TO PARTICIPATE IN THIS CONSULT GROUP?
Your answer
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