Referral Form - Kids First

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Services
- Programs
- Classes
- Counseling
- Resources
Servicios en Español
Get Involved
About

Request Services

Request Services

Request Services

Request Services

Search for:

Home Page
Services
- Programs
- Classes
- Counseling
- Resources
Get Involved
About

Request of Services 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

"*" indicates required fields

Is this service request for:*

Self

A family member

My client

My student

My patient

A friend/acquaintance

Significant other

Decline to state/anonymous

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

Yes

No

Case Management Needs (Check all that apply)*

Information and Referral to community resources and services

Maternal & Infant Healthcare Assistance

Health Insurance Enrollment Assistance

CalFresh Enrollment Assistance

Utility Discount Plan Enrollment Assistance (CARE Program)

Rental Assistance

Utility Assistance

Other

N/A

If Other, please describe:

I understand that the request for utility or rental assistance requires proof of verifiable income for the last 30 days and/or current lease agreement, and enrollment into the financial education course*

Yes, I understand

Counseling Needs (Check all that apply)*

Child

Individual

Family

Couples

Parent Child Interaction Therapy (PCIT) (2-7yrs)

Perinatal Mood and Anxiety Disorder (PMAD)/Parent Baby Wellness Program

Maternal & Infant

Trauma-Based Therapy

N/A

Additional Family Support Needed (Check all that apply)

Parents as Teachers/ Home Visitation Program (prenatal - 5 years)

After School Leadership Program

Caregiver & Parenting Classes (Incredible Years, APN, Forever Fathers, etc.)

Maternal & Infant Healthcare Program

Contact Information

Information for who is filling out the referral form

Today's Date*

MM slash DD slash YYYY

Contact Person:

First Last

Phone*

Email*

Agency Name:

Who are the services for?

Adult's Name

First Last

DOB:

MM slash DD slash YYYY

Gender

Female

Male

Non Binary

Adult's Name

First Last

DOB:

MM slash DD slash YYYY

Gender

Female

Male

Non Binary

Adult's Name

First Last

DOB:

MM slash DD slash YYYY

Gender

Female

Male

Non Binary

Child's Name:

First Last

DOB:

MM slash DD slash YYYY

Gender

Female

Male

Non Binary

Child's Name:

First Last

DOB:

MM slash DD slash YYYY

Gender

Female

Male

Non Binary

Child's Name:

First Last

DOB:

MM slash DD slash YYYY

Gender

Female

Male

Non Binary

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

REQUIRED, Please Complete

Number of Adults In Home:*

Please enter a number from 0 to 10.

Number of Children in Home:*

Please enter a number from 0 to 20.

Head of Household (HOH) Ethnicity:*

Alaskan Native / Native American

Asian

Black / African American

Hispanic / Latino

Multiracial

Pacific Islander

White / Caucasian

Unknown

Other

HOH Disability?*

Yes

No

Unknown

Female Head of Household?*

Yes

No

Unknown

Victim or at risk of Commercial Sex Exploitation?*

Yes

No

Unknown

Is there a victim of domestic violence in the home?*

Yes

No

Unknown

Select Your Health Insurance*

If Other, Please List Who*

If Medi-Cal, Anthem or CA Health & Wellness ID #*

I understand that failure to provide my insurance information may delay or disqualify me from therapy / counseling services.*

Yes, I Understand.

CalWORKS Participant?*

Yes

No

Unknown

If Yes, provide CalWORKS ID#:*

Receive CalFresh?*

Yes

No

Unknown

Enrolled in the PG&E CARE?*

Yes

No

Unknown

Additional comments?*

How did you hear about us?*

Contact Us

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TAX ID# 68-0195225

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