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 *
Last Name *
Phone Number *
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?
Clear selection
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
Last Name
Organization Name
Phone Number
Submit
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