Request for CFC Services

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Request for CFC Services

If you need immediate assistance, please call 911.Domestic Violence Services Disclaimer: To ensure the safety of each survivor seeking services, our staff do not initiate contact. You can reach our advocates for support and resources through our 24 hour/7 day a week DV hotline at: 661-259-HELP (4357).
Date

MonthDayYear
Date
Service Requested:

Mental Health ServicesSubstance Use ServicesUnsureOther
Person Making Referral:

First NameLast Name
How did you hear about Child & Family Center?

Community EventSchoolDoctorDCFSProbationOther
Organization/School:
Relationship to Client:
Relationship to Client:
If Other, Please describe:
Email
example@example.com
Phone Number

Area CodePhone Number
Client Information
Name*

First NameLast Name
Date of Birth:

MonthDayYear
Date
Gender
Email
example@example.com
Phone Number*

Area CodePhone Number
Consent to leave a Voicemail?
Type of Insurance
Medi-cal ID#
If Private Insurance, Specify Carrier:
School
Grade Level
Who Will Consent for Services
If Other, Please Describe:
Parent/Guardian/Caregiver Information

Complete if applicable
Parent/Guardian Name:

First NameLast Name
Preferred Language:
Phone Number

Area CodePhone Number
Best Times to Call
Consent to leave a Voicemail?
Email
example@example.com
Relationship to Client:
Marital Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Welfare Social Worker (if applicable)

First NameLast Name
Social Worker Phone Number (If applicable)

Area CodePhone Number
Reason for Seeking Services?
History

Divorce/SeparationMultiple PlacementsPhysical abuse historyFamily Substance use historyNeglectSexual abuse historyFamily ViolencePsychiatric HospitalizationsOther
Current Symptoms, Behaviors, Concerns:

DefianceFailing GradesExcessive worry/fearEasily DistractedTruancyGrief/LossAnxiety attacksSleep disturbance/NightmaresAnger/TantrumsDrug/Alcohol UseHallucinations/DelusionsImpulsivityFamily DifficultiesWithdrawal/IsolationGang AffiliationDepressed mood/Crying spellsSelf-harmAggressionSuicidal IdeationHomicidal IdeationOther
Have you ever had feelings or thoughts that you didn't want to live?

YesNo
Do you currently feel that you don't want to live?

YesNo
How often do you have these thoughts?
When was the last time you had thoughts of dying?
Share any relevant files including medi-cal information, custody documentations, minute orders, etc.

Browse Files

Cancelof
If you are a caregiver, please indicate any current concerns that apply to you:

Excessive worry/fearGrief/LossAnxiety attacksDrug UseAlcohol UseDepressed moodOther
Are you or the person you are referring experiencing substance use related issues?

YesNo
If you chose yes, would you like support and/or information about mental health and substance use services offered at Child & Family Center?

YesNo
Additional Comments
Please add your first and last name to the boxes below before clicking on the Submit Button.
By providing your contact information above, you are giving Child & Family Center permission to contact you. By signing, you are giving Child & Family Center consent and permission to discuss this request with the referring individual/organization. This is a HIPAA compliant and secure platform. The information you provide will be accessed by designated Child & Family Center staff only. If you do not wish to share your information electronically, please call us at: (661) 259-9439.
By providing your contact information above, you are giving Child & Family Center permission to contact you. By signing, you are giving Child & Family Center consent and permission to discuss this request with the referring individual/organization. This is a HIPAA compliant and secure platform. The information you provide will be accessed by designated Child & Family Center staff only. If you do not wish to share your information electronically, please call us at: (661) 259-9439.

First NameLast Name
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Request for CFC Services

Client Information

Parent/Guardian/Caregiver Information

Please add your first and last name to the boxes below before clicking on the Submit Button.