Referral for Services at Roots Community Health Center
Refer yourself, a patient, or client to services at Roots Community Health Center.
Client Information
Please enter the following information about the person who needs the services
First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Preferred Roots Site
Medical Services
If medical services aren't needed, please skip this section. To request a specific program, please enter the program name under "Other."
Medical Services Requested (check all that apply)
Do They Have Health Insurance?
Social Services
If social services aren't needed, please skip this section. To request a specific program, please enter the program name under "Other."
Social Services Requested
Referring Party
Please enter the following information about the person making this referral
First Name
Your answer
Last Name
Your answer
Organization Name
Your answer
Phone Number
Your answer
Submit
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