Referral

Submit a Referral

Fill out the form below to start the process for a youth in your care.

All fields on this form are required unless noted. Submissions are emailed directly to our team.

Youth Information

Basic details about the youth being referred.

First Name *

Middle Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

High School Diploma, GED, or N/A *

Diploma GED Not Applicable

Driver's License, Permit, or N/A *

Driver's License Permit Not Applicable

Criminal History? *

Yes No

Youthful Offender or Adult Offender *

Youthful Offender Adult Offender

Active Probation? *

Yes No

County

Bank Account? *

Yes No

Checking, Savings, Both, or N/A *

Checking Savings Both Not Applicable

Employed, Unemployed, or Disability *

Employed Unemployed Disability

Pursuing College or Vocational Training? *

Yes No Not Applicable

HOPE/EV Scholarship? *

Yes No

Health Conditions

Check any that apply to the youth being referred.

County DHR

Contact information for the referring case worker.

CSM Name *

CSM Email Address *

CSM Mobile Phone Number *

CSM Office Phone Number *

CSM Supervisor Name *

CSM Supervisor Email Address *

CSM Supervisor Phone Number *

Authorization

I hereby authorize: (1) the release of current psychological, comprehensive family assessment, individual service plan, education, and medical records to Rooted Together for the purpose of obtaining authorization for services to be rendered or for the payment of insurance claims (2) authorize release of medical and behavioral health information between Rooted Together, CDHR, SDHR, physicians, and insurance company(-ies) that may require filing of an insurance claim or appeal a claim on my behalf (3) authorization to the insurance company to pay Rooted Together. I hereby authorize future contact for care from Rooted Together, follow up, and continual treatment, regarding the services to be provided. The plan of care allows for Rooted Together to continue this contact, at any future time, while services are rendered.

Policy Acknowledgement *

Please check the boxes below to confirm that you have read and understood the following policies. By checking these boxes, you acknowledge that you have reviewed and comprehended the policies outlined by Rooted Together. It is essential to familiarize yourself with these policies to ensure a clear understanding of our practices and commitments to your privacy. If you have any questions or concerns, please don't hesitate to contact our office.

Referral received

Thank you for submitting a referral. Our team will review the information and follow up with next steps.

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