Referral Form

This form initiates a referral for Root-based Healing’s psychotherapy and trauma-recovery coaching services. While some may choose to schedule directly, we understand that taking that step can feel difficult. This referral option offers a gentle alternative — allowing us to reach out and have a brief conversation with the referred, to ensure the right fit and explore next steps for care.

The individual being referred must have given you their consent — verbally or in writing — before you submit this Referral Form.

Your Name *

Relationship to Referred *

I’m Seeking Services
Family Member/Loved One
Healthcare Professional/Mental Health or SUD Counselor
Community Provider (school, agency, etc.)

Name of Referred *

Age of Referred

Referred’s Phone Number

Referred’s Email Address

Service Requested *

Psychotherapy
Coaching
Unsure

Briefly describe your concerns (1-3 sentences) *

How did you hear about Root-based Healing? *