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Mental Health Referral Form

Children’s Bureau is here to help young children and youth (ages 0 to 21) and their families find ways to address issues that may affect the psychological health of the family and to meet their mental health treatment needs.
Please fill out the form below to get started.

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    Mental Health Referral Form

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  • Thank you for taking the time to complete this form. We're excited to hear from you and will need some information to get started. Please complete all applicable fields.
  • Person Making Referral
  • Client Information
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Parent/Guardian/Caregiver Information
  • Total in Household
  • Complete if ward of the court:
  • Please send Court Minute Order
  • Reason for referral to mental health services/therapy. Please check all that apply. Medical Necessity = Functional Impairment in Home, School or Community
  • To be completed by parent/legal guardian.
    If you are interested in having your child receive our services, please sign this release form giving Children’s Bureau’s mental health program permission to contact you. By signing this form, you are giving Children’s Bureau consent and permission to discuss the status of your case with the referring organization.
  • Drop files here or
    Max. file size: 50 MB.
      Please upload any pertinent files such as court order documents, caregiver ID, Medi-cal Forms/Card, Social Security Card and Proof of address if different from ID etc.
    • This field is for validation purposes and should be left unchanged.