Tewa Roots Society Clinical Services 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 clinical care at Tewa Roots Society. 

Please answer each question thoroughly. 

If you are unsure about how to answer any question, please let us know in the answer section. If any of the questions do not apply to you, please type "N/A". 
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Requester First and Last Name (and organization, if applicable) *
Requester Phone Number *
Requester Email Address *
If the referred client 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:
Client First and Last Name *
Client Date of Birth *
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Client Phone Number *
Client Email Address *
Client Physical Address *
Client Tribal Affiliation  *
Is Client currently incarcerated? *
If Client is incarcerated, please provide the necessary contact information. *
Reason for referral (please be as thorough as possible) *
Please select the type of service(s) Client is interested in:

(All services are in-person unless otherwise stated)
 *
Required
If any group, couples, or family services were selected, please list the names of those who are interested in participating and their relationship to the Client:  *
When would the Client like to begin receiving services? (Please select today's date if Client would like to be seen as soon as possible) *
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Notes, comments, or questions?
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