Restorative Roots Referral Form There was an error trying to submit your form. Please try again. Full Name * Enter your full name as the referring provider. This field is required. License Type and Number * Specify your professional license type and corresponding number. This field is required. Practice Name * Enter the name of your practice or organization. This field is required. Email Address * Provide a valid email address for contact. This field is required. Phone Number * Enter your phone number to reach you for follow-up questions. This field is required. Client Initials or First Name * Enter the client's initials or first name only (no full name required). This field is required. Client Age * Specify the client's age. This field is required. General Reason for Referral * Provide a brief description of the reason for this referral. This field is required. Has the Client Expressed Interest in KAP? * Indicate if the client has shown interest in ketamine-assisted psychotherapy. Yes No This field is required. Relevant Clinical Considerations Include any relevant clinical details that may assist in managing the referral (optional). Consent Confirmation * Confirm that you have discussed this referral with the client and obtained appropriate consent to share this information. This field is required. Submit There was an error trying to submit your form. Please try again.
