Referral Form Get Mental Health Support Today – Covered by Medi-Cal Referral FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Preferred Contact Date Full Name *Date of Birth *Phone Number *Email *Preferred Contact Method *PhoneEmailTextInsurance Type *Medi-CalPrivate InsuranceNo InsuranceReason for Referral (Check All That Apply) *AnxietyDepression & Mood DisordersTrauma/PTSDSevere Mental Illness (SMI)Medication ManagementLife stressorsRelationship IssuesOtherCurrent Services *Is the client receiving services? Does the client have a case manager? Who is the referral Source: (Case manager, Doctor, Self or Other)Preferred Session TypeTelehealth (Online)In-Person (At Our Office in Antelope Valley)Field Service (In home or other field location)Additional Notes *Briefly describe any urgent concerns or additional details.Submit
