Referral Form
Note: If this is a mental health-related emergency, please call 988, the Suicide & Crisis Lifeline. For other emergencies, call 911 or go to the nearest hospital.
Do you or the child you are referring to services, currently have Medi-Cal insurance?
Select an option
Yes
No
We are only accepting Medi-Cal insurance at this time. Please check with your insurance for providers in your network
Are you inquiring about School Based Mental Health Services or Outpatient Mental Health Services?
Select a service
School Based
Mental Health
Please select a service
Please select a location
Submit