Referral

Referral
Intake Phone: 323-274-3075
Intake Fax: 323-967-0619
Intake Email: intake@hillsides.org
Is the client being referred:
Referral Type:
School Name:
Referred By:
Name:

First NameLast Name
Relationship to Client:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Client's Identifying Information:
Client Name:

First NameMiddle NameLast Name
Gender:
D.O.B:

MonthDayYear
Date
Age:
Social Security #:
Primary Language:
Race/Ethnicity:
School Name, if applicable:
Grade, if applicable:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Okay to leave message?
Please indicate type of coverage client has:
Which insurance provider do you have?
If yes, Medi-Cal #:
How would client like services to be provided?
Services are provided virtually.
Primary Caregiver Information of Client:
Client currently lives with (check all that apply):
Mother's Name:

First NameLast Name
Father's Name:

First NameLast Name
Guardian's Name:

First NameLast Name
Foster Parent's Name:

First NameLast Name
Other - Specify Caregiver Name:

First NameLast Name
Caregiver's Primary Language:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Okay to leave message?
Experiencing the Following (check all that apply):
Parent/Caregiver/ Client would like therapy to address the following concerns (Ex: Suicidal Ideation, Hyperactive, Anxious, Defiance, Difficulty Concentrating, Sadness, etc.):
Biological Mother's Name:

First NameLast Name
Biological Father's Name:

First NameLast Name
Is there a custody order in place?
Has the client had any traumatic experiences?
Provide additional information regarding traumatic experiences:
History of Domestic Violence?
Provide additional information regarding Domestic Violence history:
DFCS Involvement:
Provide additional information regarding DCFS involvement:
Prior Episodes/Psychiatric hospitalizations/Psychiatric Hx:
Provide additional information regarding prior history:
Medical Issues (ex: asthma, diabetes, etc.)
Provide additional information regarding medical issues:
Should be Empty:

Referral

Referred By:

Client's Identifying Information:

Primary Caregiver Information of Client: