KidsFirst Services Request Form

Caregiver/Adult's Name: (Required) *

First

Last

Other names Caregiver/Adult goes by?

Phone Number:

DOB:

Child's Name:

First

Last

DOB:

Would You Like To Add Another Child?

Yes
No

Child's Name:

First

Last

DOB:

Would You Like To Add A Third Child?

Yes
No

Child's Name:

First

Last

DOB:

Address:

Address Line 1

City

State

Zip Code

If no address:

Homeless

Please specify:

Email address of person that will receive KidsFirst Services:

CASE MANAGEMENT (Check all that apply)(Required) *

Information and Referral to community resources and services
Health Insurance Enrollment Assistance
Utility Discount Plan Enrollment Assistance (CARE Program)
CalFresh Enrollment Assistance
Housing Assistance
Other

If Other, please describe

COUNSELING (Check all that apply)

ADDITIONAL FAMILY SERVICES (Check all that apply)

Parents as Teachers (Pre-natal - 5 years old)
Parenting Classes and Male Caregiver Support Group
Supervised Visitation @ Parenting Time Vouchers (Pre-natal - 5 years old)

Are you pregnant?

Yes
No

Is this service request for: (Required) *

If making a referral for someone other than yourself, please complete this section so that you may be contacted

Contact Person:

First

Last

Phone Number:

Agency Name:

Email:

Is it okay to share the service request information you provided here with the person that you are requesting services for?

Yes, it's okay to share
No, I want it to be confidential

REQUIRED, PLEASE COMPLETE:

Head of Household (HOH) Ethnicity: (Required) *

If Other, explain

HOH Disability? (Required) *

Yes
No
I don't know

Estimated Household Gross Annual Income:

Enter $$$ Amount

Check here if Estimated Household Gross Annual Income is

Unknown

Number of Adults in Home: (Required) *

Number of Children in Home: (Required) *

Health Insurance? (Required) *

Yes
No
I don't know

If Yes, which provider?

If Medi-Cal, Anthem or CA Health & Wellness ID No:

CalWORKS Participant? (Required) *

Yes
No
I don't know

If Yes, provide CalWORKS ID No:

Receive CalFresh? (Required) *

Yes
No
I don't know

Enrolled in the PG&E CARE? (Required) *

Yes
No
I don't know

Female Head of Household? (Required) *

Yes
No
I don't know

Victim or at risk of Commercial Sex Exploitation? (Required) *

Yes
No
I don't know

How did you hear about us? (Required) *

Additional Comments:

FOR MDIC/DA's OFFICE ONLY

Is this a MDIC follow up?

Yes
No
I don't know

Date of MDI

Is this a confidential SCAN referral only?

Yes
No
I don't know