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Referral for Services at Roots Community Health Center
Refer yourself, a patient, or client to services at Roots Community Health Center.
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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
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)
Other:
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)
Primary Care Doctor/Nurse Practitioner
Immigration Visit
Family Planning/STD Testing
Complex Care
Diabetes Care
Diabetes Classes
Hepatitis C Treatment
High Blood Pressure (Hypertension) Care
Medication Assisted Therapy (suboxone)
Mental Health - Medication Management
Mental Health Counseling
Other:
Do They Have Health Insurance?
Yes
No
Other:
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
Food
Housing
Clothes Closet
General assistance
Utilities
Re-entry services
Family navigation
Dental resources
Health Insurance or PCP change to Roots
Employment assistance
GED/High School Diploma
College Degree/Trade Certificate
Cell phone
Birth Certificate
Social Security Card
Credit Report
ID Voucher
Mailbox
Diapers
Carseats
Other:
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
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