Mental Health Referral Form
CLIENT INFORMATION
Referral Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child/Youth Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Legal/Assigned Sex
*
Male
Female
Gender Identity (if different)
Medi-Cal #
*
Current Grade
*
Preferred Language
*
Current School
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
CONTACT INFORMATION
Has Legal Representation been contacted and informed of referral?
*
Yes
No
Legal Representative's Name
First Name
Last Name
Legal Representative's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Representative's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Referral
*
(Behaviors/symptoms; current medications; medical problems/conditions that may warrant Mental Health Services)
Name & Title of Person Referring Client/Student
*
Submit
Should be Empty: