Counseling4Kids Referral Form 2025

Title/Name:
Referring Party Name:
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Open DCFS Case:*

YESNO
Social Worker Name:
Phone Number:
Please enter a valid phone number.
Social Worker Email:
example@example.com
(If referred by a C4K Provider please provide our C4K providers name here):

First NameLast Name

School Referral | Documents needed:
- Signed Consent Form
- Custody paperwork (if applicable)
- Child's Medi-Cal Card
- Copy of driver's license or I.D.
Voluntary | Documents needed:
- Custody paperwork (if applicable)
- Child's Medi-Cal Card
- Copy of driver's license or I.D.
Court Ordered | Documents needed:
- Minute Order, Stand Alone, Or MH-179
- Detention Report (if available)
MAT Referral | Documents needed:
- Copy of MAT Assessment
- Summary of Findings
- CANS
- Court documents
Upload documents (adoption paperwork, legal guardianship paperwork, custody agreements, and/or signed school consent form):

Cancelof

Please verify that you are human*
IMPORTANT REMINDER! Once you hit submit, you'll know we've received your referral when you see our thank you message. We'll also send you a confirmation email, so please check your spam folder just in case.
Should be Empty: