Tapestry Family Services
Online Referral Form
Date of Referral
*
/
Month
/
Day
Year
Date
Name of Person Providing Referral
*
Phone # of Person Providing Referral
*
Format: (000) 000-0000.
Referred by (select one):
*
Please Select
Individual
Agency
School
Family & Children Services
FCS - FEG
Please specify name of Agency or School
*
Referring Party Relationship to Client
*
Please choose the type of referral you are making:
*
Behavioral Health
School Based Services
Client Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Is the client's parent/guardian aware of this referral?
Yes
No
Client's Primary Language
*
Client's Gender
*
Client's Ethnicity
*
Client's Medi-Cal Number
Client's Social Security Number
Does the client have other health insurance besides Medi-Cal?
*
Yes
No
What is the other health insurance company and policy number?
Parent/Legal Guardian Name
*
Relationship to Client
*
Legal/Custody Status
*
Physical Address
*
STREET ADDRESS
Street Address Line 2
City
State / Province
ZIP CODE
Mailing Address
MAILING ADDRESS
Street Address Line 2
City
State / Province
ZIP CODE
Cell Phone Number
*
Format: (000) 000-0000.
Home Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Client's School Name
Grade
Reason for Referral
*
Has the client received Mental Health Services (counseling) with another agency?
Yes
No
If yes, what agency & counselor's name:
Does this client:
Receive services from RCRC?
Receive services in school through an IEP?
Have a current social worker?
Registered with Behavioral Health Court?
Social Worker Name and Phone #
Behavioral Health Court Judge Name
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