Referral Form

Get Mental Health Support Today – Covered by Medi-Cal
Self-Referral / Referral Form (Adults 18+)

Referral Form
Reason for Referral (Check All That Apply)
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 Type
Briefly describe any urgent concerns or additional details.

Common questions

Do I need a referral from my doctor?
No. You can self-refer. Most people, families, and providers contact us directly using this form or by phone.

How long until I hear back?
We usually contact you within 1–2 business days to confirm Medi-Cal eligibility, medical necessity, and next steps.

What if I’m not sure I qualify?
You can still submit the form. If you want a simple explanation first: read our step-by-step guide →

What insurance do you accept?
We accept Medi-Cal covered mental health services for adults 18+ in Los Angeles County, including the Antelope Valley. Your Medi-Cal plan type is confirmed during intake — if you have active Medi-Cal in LA County, you can submit this form.

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