Tewa Roots Society Clinical Therapy Referral
Please fill out the following referral form to the best of your ability. You can refer yourself or another individual who is interested in receiving care through Tewa Roots Society. 

Please answer each question thoroughly. 

If you are unsure about how to answer a question, you can write something like "?" or "unsure." If the questions do not apply to you or the person you are referring, please write "N/A". 
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Requester First and Last Name (and Organization, if applicable) *
Requester Phone Number *
Requester Email Address *
If the referred person is younger than 14 years old OR a vulnerable adult who needs living and/or decision-making assistance, please answer the following questions:

(Enter "N/A" if this does not apply to you)
Parent/Guardian Name(s) *
Parent/Guardian Phone Number *
Parent/Guardian Email Address *
Parent/Guardian Physical Address *
Client Information: Yourself or adult you are referring (14 years old or older) 
Client First and Last Name *
Client pronouns (check all that apply)
click here to learn about pronouns *
Required
Client Date of Birth *
MM
/
DD
/
YYYY
Client Phone Number *
Client Email Address *
Client Physical Address *
Client Tribal Affiliation  *
What insurance do you / the person you're referring have? (select primary insurance) *
Required
If the person you're referring is incarcerated, please provide the necessary contact information. *
Have you / the person you're referring received a court order for therapy or are on probation currently? *
Reason(s) for referral (check all that apply and fill in "other" if needed) *
Required
Anything else you'd like us to know?
Please select the type of service(s) you / the person you're referring are interested in: *
Required
What are some activities that you / the person you're referring would like to do in therapy? (check all that apply and fill in "Other" if needed) *
Required
How would you / the person you're referring prefer to meet with your therapist? *
Required
When can you be available to meet with your therapist? (check all that apply)
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
9am
10am
11am
noon
1pm
2pm
3pm
4pm
5pm
6pm
Please ask us any questions you have! We will get back to you as soon as possible.
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