KidsFirst Services Request Form

Is this referral for someone that either lives, has children in, or has an open CPS case in Placer county.? *

Yes
No

DO NOT CONTINUE FILLING OUT THIS FORM.

We apologize, but we will not be able to process your referral at this time. Please call our office at (916) 774-6802 with any further questions.

Caregiver/Adult's Name: (Required) *

First

Last

Other names Caregiver/Adult goes by?

Phone Number:

Parent/Caregiver Date of Birth (DOB):

Child's Name:

First

Last

Child's Date of Birth (DOB):

Would You Like To Add Another Child?

Yes
No

Child's Name:

First

Last

Child's Date of Birth (DOB):

Would You Like To Add A Third Child?

Yes
No

Child's Name:

First

Last

Child's Date of Birth (DOB):

Home Address:

Address Line 1

City

State

Zip Code

If no address:

Unhoused

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 Utility to Housing/Utility 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)
Caregiver/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

The commercial sexual exploitation of children (CSEC) is the sexual abuse or exploitation of a child, for the financial benefit of any person, or in exchange for anything of value, including monetary and non-monetary benefits. All commercially sexually exploited minors are victims, regardless of the presence of force, fraud, or coercion.

Would you or the person being referred like assistance with any of the following: locating COVID-19 vaccine information or making a vaccine appointment? *

Yes
No
Unknown

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