Please choose an internal referral type below

Roots Recovery Internal Referral Form

  • Referent Information

  • MM slash DD slash YYYY
  • Client Information

  • Client Needs

  • Check all that apply
  • Please provide any more information you feel is pertinent to help us process this referral and effectively deliver services to this client.

Roots Recovery Internal Therapy Referral Form

Use this form to refer Roots clients to see a Roots therapist or dietitian.
  • Service Needs

  • Check all that apply