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.
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.
Okay to leave message?*

YesNo
Please indicate type of coverage client has:*

Medi-calCommercial InsuranceNonePay out-of-pocket
Which insurance provider do you have?
If yes, Medi-Cal #:
How would client like services to be provided?*

VirtualIn-PersonHybrid (virtual and in-person)
Services are provided virtually.
Primary Caregiver Information of Client:
Client currently lives with (check all that apply):

MotherFatherGuardianFoster Parent(s)SelfOther
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.
Alternate Phone:
Please enter a valid phone number.
Okay to leave message?*

YesNo
Experiencing the Following (check all that apply):

Suicidal: Ideations/ Hx/ Intent/ Self HarmHomicidal: Ideation/ Hx/ IntentHx of Abuse/ Trauma/ DV/ BullyingAggression/ Destruction of PropertySadness/ Depressed/ Cries OftenHallucinations (Visual, Auditory, etc)Difficulties at SchoolDisruptive BehaviorsIrritabilityDifficulty ConcentratingTemper Tantrum/ Mood ChangesDefiance/ Non-compliantImpulsive/ Hyperactive/ InattentivesIsolation/ WithdrawalFlashbacksFearfulnessNightmaresAnxious
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?

YesNo
Has the client had any traumatic experiences?*

YesNo
Provide additional information regarding traumatic experiences:
History of Domestic Violence?*

YesNo
Provide additional information regarding Domestic Violence history:
DFCS Involvement:*

YesNo
Provide additional information regarding DCFS involvement:
Prior Episodes/Psychiatric hospitalizations/Psychiatric Hx:*

YesNo
Provide additional information regarding prior history:
Medical Issues (ex: asthma, diabetes, etc.)*

YesNo
Provide additional information regarding medical issues:
Should be Empty:

Referral

Referred By:

Client's Identifying Information:

Primary Caregiver Information of Client: