Mental Health Referral Form

Minor Guardian & Contact Details

Put N/A if this does not apply
Who has custody of the client?*

ParentsCountyOther
Parent/Guardain Information. Please enter primary guardian first and include all parfties with guardianship or custody status.
Parent/Guardian 1*
Relationship*
Custody Status*
Phone Number*
Parent/Guardian 2*
Relationship*
Custody Status*
Phone Number*
Parent/Guardian 3
Relationship
Custody Status
Phone Number
Parent/Guardian 4
Relationship
Custody Status
Phone Number

Please provide any additional information you think we should have to facilitate this referral.
You may upload file attachments below. Please include the following, if applicable: Diagnostic Assessment, CHIPS petition, Release of Information, Court Orders, etc.

Cancelof
I authorize the release of the above referral information to Roots Wellness Center for the purpose of evaluation and treatment. I understand that additional consent may be required for further coordination of care.
ClientGuardianReferring Provider Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Client Information