Referrals

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Referrals

Client's Full Name *

First Name

Last Name

Legal Gender *

Client's Date of Birth *

Is Client Under 18 Years of Age? *

Client's Street Address, City, State, and Zip Code *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Who is Completing the Referral? *

Self/Guardian

Doctor

DFCS

School

Court

DJJ

Insurance

Other

Name of Person Making the Referral (If Not a Self-Referral)

Phone Number for Person Making the Referral *

Email Address for Person Making the Referral *

Type of Services Requested *

Psychiatry

Counseling

Reason for Referral *

Type of Insurance *

Insurance ID Number

Medicaid/CMO ID Number (If Applicable)

Client's Phone Number *

Thank you for sending the referral!

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Roots Wellness Center, LLC

Roots Wellness Center is a place to grow. We are a comprehensive behavioral health organization offering services to children, adolescents, and adults.

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