Referral Form, Mental Health

Mental Health Referral Form

This referral form should be completed by individuals who are seeking mental health services at License to Freedom. Agencies, family members and friends can also complete this form on behalf of an individual who may need mental health services. Once completed, our Clinical Director of Family Therapy Services will reach out within 48 hours.
License to Freedom services are available only to refugees and immigrants. Please confirm that the client is a refugee or immigrant.*

YesNo
Name of individual completing the form*

First NameLast Name
Enter your email (if you do not have email type "123@noemail.com")*
example@example.com
Enter your phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Is this referral being submitted by an agency or organization (e.g., school, nonprofit, healthcare provider, legal services, or government agency)*

YesNo
Enter the name of the agency or organization*
Please let us know who this referral is for:*

I am seeking services for myselfI am referring someone else for services
Client Full Name*

First NameLast Name
Client Email Address (if you do not have email type "123@noemail.com")*
example@example.com
Client Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Gender of the Client*

FemaleMaleOther
Can our team safely reach out to the client using the contact information provided?*

YesNo
If no, please explain*
Primary Language/Native Language*

AmharicArabicDari/FarsiEnglishFrenchHaitian-CreoleKurdishNuerPashtoRussianSomaliSpanishTagalogTigrinyaUkrainianOther
Does the client require an interpreter?*

YesNo
Is the client required to attend therapy? In other words, is this therapy court-ordered or otherwise mandated?*

YesNoNot sure
What is the client's availability to meet with our therapist?

MondayTuesdayWednesdayThursdayFriday
Preferred timeframes (select all that apply)

Morning (8am to 12pm)Afternoon (12pm to 4pm)Evening (4pm to 7pm)
Other notes or comments you would like the mental health team at License to Freedom to know about the client?
Thank you. However, we only offer our mental health services to refugees and immigrants. To find mental health services and other services, you can contact 211 San Diego or check out their website: https://211sandiego.org/.
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Mental Health Referral Form