La Familia Central Valley Referral Form
Client Information
Full Name of the Client being Referred
*
First Name
Last Name
Is the client being referred a minor?
Yes
No
Parent/Guardian name(s)
First Name
Last Name
Parent/Guardian phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Language
*
Reason for Referral or Additional Notes
*
Have you discussed this referral with your client or their guardian and are they aware you are referring them to La Familia?
*
Yes
No – we encourage you to discuss this specific referral with your client before proceeding with completing this referral form.
Services Requested
What type of service(s) are being requested:
Mental Health Counseling
Case Management
Enhanced Care Management (ECM)
Substance Use Disorder (SUD)
Do you know which La Familia program would best suit this individual? (Not required, our intake coordinator will match the client to the appropriate program.)
Outpatient Mental Health Counseling
Outpatient SUD Counseling
Mobile Mental Health
Stan Connect
Enhanced Care Management (ECM)
Select the ECM Population(s) of Focus that this member would qualify under. La Familia staff will confirm Population of Focus and eligibility prior to enrolling in the ECM program.
Adults Experiencing Homelessness
Homeless Families or Unaccompanied Children/Youth Experiencing Homelessness
Adults at Risk for Avoidable Hospital or ED Utilization
Children/Youth at Risk for Avoidable Hospital or ED Utilization
Adults with Serious Mental Health and/or Substance Use Disorder (SUD) Needs
Children/Youth with Serious Mental Health and/or Substance Use Disorder (SUD) Needs
Adults Transitioning from Incarceration within the past 12 months
Children/Youth Transitioning from Youth Correctional Facility within the past 12 months
Adults Living in the Community who are at Risk for LTC Institutionalization
Adult Nursing Facility Residents transitioning to the Community
Children/Youth Enrolled in CCS or CCS WCM with Additional Needs beyond the CCS Condition
Birth Equity Adults
Birth Equity Youth
Insurance Information
Insurance Plan
Insurance Plan ID
Referring Party Information
Your Full Name
*
First Name
Last Name
Your Organization:
Your Email Address
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Referral
Should be Empty: