New Mental Health Client Referral

New Mental Health Client Referral
Thank you for choosing Roots Wellness Center. Please complete this form to submit a new referral for our mental health services.

Click 'Next' to continue.
COVID-19 Service Notice
COVID-19 has required that we move most of our services to the Zoom teletherapy platform. All that is required to take advantage of this is a smart device with internet access and a camera. Please indicate the client's ability to utilize teletherapy services below.*

Client has the technology, internet access and support to access teletherapy servicesClient has access to internet but may need assistance with getting a device to access teletherapy services.Client does not have consistent access to internet or technology to access teletherapy services.Unknown

Referent Information
Referent Name*
Referent Organization*
Referent Phone Number*
Please enter a valid phone number.
Referent Email*
example@example.com
What is your relationship to the client? (current therapist, case manager, family member, self referral, etc)*

Additional Information & File Uploads
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
File Upload

Cancelof
Is there an ROI attached to allow Roots Wellness Center to update you?*

YesNo
Is a current/recent Diagnostic Assessment available? (attach if possible)*

YesNo
Should be Empty:

Minor Guardian & Contact Details