Referral Form – Kids First

KidsFirst Services Request Form

A variety of free and low cost programs are available to qualifying individuals through KidsFirst.

Please complete the form below and click submit at the bottom of this page

Step 1 of 2

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

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?

Home Address:

Address Line 1

City

State

Zip Code

If no address:

Unhoused

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

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)

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:

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

CalWORKS Participant? (Required) *

Yes
No
I don't know

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

Message

Please note that the service request form cannot be successfully submitted until all noted areas with a red asterisk (*) are completed.

Thank you for submitting your service request form. A KidsFirst team member will receive your request within one business day and will be in contact with you or the individual you referred within 3-5 business days. Please contact us at kidsfirst@kidsfirstnow.org or (916) 774-6802 if you have any questions. If you or your child is experiencing a mental health emergency please call 9-1-1 or the Placer County Adult Crisis & Intake 24-hour line at (916) 787-8860 or the Placer County Children’s 24-hour mental health crisis line at (916) 872-6549. Additional community resource information can also be found by calling 2-1-1 or visiting: https://211connectingpoint.org/placer-county/. Additionally, The Homeless Resource Helpline is 1-833-3PLACER.

KidsFirst Services Request Form

DO NOT CONTINUE FILLING OUT THIS FORM.

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

REQUIRED, PLEASE COMPLETE:

FOR MDIC/DA's OFFICE ONLY

Please note that the service request form cannot be successfully submitted until all noted areas with a red asterisk (*) are completed.

KidsFirst Counseling & Family Resource Centers

KidsFirst
Roseville

KidsFirst
Auburn

KidsFirst Services Request Form

DO NOT CONTINUE FILLING OUT THIS FORM.

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

REQUIRED, PLEASE COMPLETE:

FOR MDIC/DA's OFFICE ONLY

Please note that the service request form cannot be successfully submitted until all noted areas with a red asterisk (*) are completed.

KidsFirst Counseling & Family Resource Centers

KidsFirstRoseville

KidsFirstAuburn

KidsFirst
Roseville

KidsFirst
Auburn