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  • ROOTS WELLNESS CENTER

    ROOTS WELLNESS CENTER

    Empowering our community through holistic, cultural, somatic, and systematic support.

  • Referring Party Information

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  • Is this a referral for an adult or minor child?*
  • Format: (000) 000-0000.
  • Relationship to the client:*
  • Will there be a ROI attached to allows us to update you? (if yes, please upload at the end of the referral form).*
  • Is a current/recent diagnostic assessment available?*
  • Client Information

    Client Information

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  • Gender Identity*
  • Format: (000) 000-0000.
  • Best time to call:*
  • Preferred method of contact:*
  • Address type*
  • Minor Guardian & Contact Details

    Minor Guardian & Contact Details

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

  • Parent/Guardain Information. Please enter primary guardian first and include all parfties with guardianship or custody status. 

     

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Service Needs & Primary Concerns

    Service Needs & Primary Concerns

  • Primary Concerns (check all that apply)*
  • Service Requested*
  • Preferred Method of Services:*
  • If a specific provider or culturally specific provider isn't available, is the client willing to see the soonest provider?*
  • Is an interpreter needed?*
  • Client availability for services:*
  • Insurance & Financial Information

    Insurance & Financial Information

  • Is this commercial insurance?*
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  • 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.

     

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