Request for CFC Services
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
-
Month
-
Day
Year
Date
Service Requested:
Mental Health Services
Substance Use Services
Unsure
Person Making Referral:
First Name
Last Name
Organization/School:
Relationship to Client:
Relationship to Client:
Self
Parent/Legal Guardian
Informal Caregiver
DCFS Social Worker
School Counselor
DMH Case Worker
Primary Care Physician
Other (Please Describe)
If Other, Please describe:
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Client Information
Name
*
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Non-Binary
Other
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Consent to leave a Voicemail?
Yes
No
Type of Insurance
Medi-cal
Uninsured
Private Insurance
Other
Medi-cal ID#
If Private Insurance, Specify Carrier:
School
Grade Level
Who Will Consent for Services
Consenting for own services
Parents (Married)
Parents (joint legal custody)
Parent (single)
Legal Guardians (joint Legal Custody)
Legal Guardian (Single)
Foster Parent(s)
Adoptive Parent(s)
Informal Caregiver (no legal documents)
Other (Please describe)
If Other, Please Describe:
Parent/Guardian/Caregiver Information
Complete if applicable
Parent/Guardian Name:
First Name
Last Name
Preferred Language:
Phone Number
-
Area Code
Phone Number
Consent to leave a Voicemail?
Yes
No
Email
example@example.com
Relationship to Client:
Marital Status
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Welfare Social Worker (if applicable)
First Name
Last Name
Social Worker Phone Number (If applicable)
-
Area Code
Phone Number
Reason for Seeking Services?
History
Divorce/Separation
Multiple Placements
Physical abuse history
Family Substance use history
Neglect
Sexual abuse history
Family Violence
Psychiatric Hospitalizations
Current Symptoms, Behaviors, Concerns:
Defiance
Failing Grades
Excessive worry/fear
Easily Distracted
Truancy
Grief/Loss
Anxiety attacks
Sleep disturbance/Nightmares
Anger/Tantrums
Drug/Alcohol Use
Hallucinations/Delusions
Impulsivity
Family Difficulties
Withdrawal/Isolation
Gang Affiliation
Depressed mood/Crying spells
Self-harm
Aggression
Suicidal Ideation
Homicidal Ideation
Have you ever had feelings or thoughts that you didn't want to live?
Yes
No
Do you currently feel that you don't want to live?
Yes
No
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
Cancel
of
Submit
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.
Clear
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 Name
Last Name
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