Roots Wellness Internal Referrals
Is this referral for an adult or a minor child?
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Adult
Minor Child
What type of referral would you like to make?
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CTSS
ARMHS
Therapy
Pretrial Navigaton
Outpatient Treatment
Children's Day Treatment
Adult Case Management
Date of Referral
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-
Month
-
Day
Year
Date
Referring Staff Name
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First Name
Last Name
Referring Staff Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Referring Staff eMail:*
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Is client already in Procentive?
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Yes
No
Client Name
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First Name
Middle Name
Last Name
Client Date of Birth
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-
Month
-
Day
Year
Date
Client Social Security Number
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for insurance verification
Client Gender
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Female
Male
Genderqueer/Non-Binary
Trans
Prefer not to disclose
Other
Client Race/Ethnicity
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African-American
Asian-American
Native American
Latinx
East-African
West-African
Caucasian/White
Multiracial/Other
Prefer Not to Say/Other
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Community Partner Contact Name (schools, PPL, FastX, CSP, etc):
Community Partner Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Services Requested
Date of Referral
*
-
Month
-
Day
Year
Date
Referring Staff Name
*
First Name
Last Name
Referring Staff Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Staff Email
*
example@example.com
Is client already in procentive?*
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Yes
No
Client Name
*
First Name
Middle Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Social Security Number
for insurance verification
Client Gender
*
Female
Male
Genderqueer/Non-Binary
Trans
Prefer not to disclose
Other
Brief description of reason for referral:*
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Please provide any more information you feel is pertinent to help us process this referral and effectively deliver services to this client.
MH Services Requested
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Diagnostic Assessment
DC 0-5 - Infant/Child Diagnostic
Individual ARMHS-Skills
Individual CTSS-Skills
Individual Therapy
TeleTherapy (Video)
Other
IOP Services Requested
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Adult IOP w/Sober Housing
Adult IOP w/o Sober Housing
Adult Step-Down IOP
Comprehensive Assessment
N/A
Has client recently completed a comprehensive assessment or Substance Use Assessment?
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Yes
No
Unsure
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Refer MH Client to Roots
Date of Referral
*
-
Month
-
Day
Year
Date
Referring Staff Name
*
First Name
Last Name
Referring Staff Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Staff eMail:*
*
example@example.com
Client Name
*
First Name
Middle Name
Last Name
Client Primary Counselor Name
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First Name
Last Name
Client Primary Counselor Email*
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Roots clients must be enrolled and participating for a minimum of 3 weeks prior to starting therapy. Has this client been enrolled for 3 weeks?*
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Yes
No
Type of Referral:*
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Mental Health Therapy
Nutrition/Dietitian Counseling
Both
Services Requested:*
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Mental Health Individual Therapy
Trauma-Focused Therapy
Couples Therapy
Family Therapy
Skills-Based/DBT Therapy
LOCUS - Needed for ARMHS/TCM
Functional Assessment - Needed for ARMHS
Updated Diagnostic Assessment
Other Services
Preferred Method of Services
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In-Home / Community ONLY
Telehealth / Zoom ONLY
Either In-Home or Telehealth
Client preference for worker (e.g., cultural, gender, language, etc):
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If a specific provider or culturally specific provider isn't available, is the client willing to see the soonest available provider?
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Yes
No
Briefly explain the reason for the referral. What symptoms/issues are presenting?*
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Does client have any of the following services in place?
Psychotherapy
ARMHS/Case Management
Psychiatry
DBT
Anger Management
Domestic Abuse Programming
Day Treatment/MH IOP
Please indicate if you or the client have any preferences for specific therapist, telemedicine, days/times, etc:*
*
Additional Information:
Additional Information about this referral:
Please provide any more information you feel is pertinent to help us process this referral and effectively deliver services to this client.
Click 'Submit Internal Referral' below to complete your referral.
Submit Internal Referral
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