Referral for Services at Roots Community Health Center
Refer yourself, a patient, or client to services at Roots Community Health Center.
Please enter the following information about the person who needs the services
Preferred Roots Site
Roots Main in Oakland (Adult Clinic & Social Services)
Roots Pediatric Clinic in Oakland (Pediatric Clinic, Ages 0-18)
Dream Youth Clinic (Youth Clinic, Ages 13-18)
Covenant House in Oakland (Youth Clinic, Ages 18-24)
Roots South Bay in San Jose (Adult Clinic, Limited Social 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)
Primary Care Doctor/Nurse Practitioner
Family Planning/STD Testing
Hepatitis C Treatment
High Blood Pressure (Hypertension) Care
Medication Assisted Therapy (suboxone)
Mental Health - Medication Management
Mental Health Counseling
Do They Have Health Insurance?
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
Health Insurance or PCP change to Roots
GED/High School Diploma
College Degree/Trade Certificate
Social Security Card
Please enter the following information about the person making this referral
Never submit passwords through Google Forms.
This form was created inside of Roots Community Health Center.
Terms of Service