SAFETY EXIT
Skip to content
Contact Us
Court Ordered Fees
Employment
HIDE THIS SITE
Search for:
50 Years
About Us
Overview
Fact Sheet
Staff Leadership
Volunteer Leadership
Strategic Plan & Financials
Services & Response Data
Employment
Contact Us
Title VI Notice to the Public
Services
Program Overview
Domestic Violence & Child Abuse Prevention
Human Trafficking Prevention & Intervention
Justice Services
Mental Health & Trauma Treatment
Youth Crisis & Homeless Services
211 Information and Assistance
News & Events
Hope & Light 2024
Love is Brewing 2024
Interface in the News
Blog: Interface Today
Resources
Get Involved
Interface Program Champion
Become a volunteer!
Employment
Donate
Donate Now!
Ways to Give
Special Funds
Where Does My Gift Go?
Mental Health & Trauma Treatment Services Form
Mental Health & Trauma Treatment Services Form
icfs-web
2024-03-20T18:14:14+00:00
*Indicates a required field
Please enable JavaScript in your browser to complete this form.
Referring person/Persona que refiere:
*
First
Last
Date/Fecha:
*
Name of referral agency or school/ Nombre de agencia o escuela refiriendo:
*
Phone/Telefono:
*
Email/Correo electrónico:
Client name/Nombre del cliente:
*
First
Last
Client DOB/Fecha de nacimiento:
Gender/Genero:
Address/Domicilio:
Medi-Cal # (if applies)/# de Medi-Cal:
Parent or guardian name/Nombre del padre o persona-custodia:
*
First
Middle
Last
Relationship to client/Relación con el cliente:
*
Parent
Legal Guardian
Caregiver
Parent or guardian primary language//Idioma primario del padre o custodia:
English
Spanish
Other
Primary contact phone number/# teléfono Primario:
*
Additional contact number/# teléfono adicional:
Permission to leave messages?/¿Permiso para dejar mensajes?:
Yes/Sí
No
Presenting issue/Asunto presente:
*
Is family aware of the referral?/¿Fue la familia notificada de la referencia?:
*
Yes/Sí
No
I understand that I am being referred to Interface Children & Family Services. I hereby give my consent for the exchange and release of information for this purpose./ Entiendo que estoy siendo referido/a los servicios de Interface Children & Family. Por lo presente doy mi consentimiento para el intercambio y divulgación de la información para este propósito.
*
Yes/Sí
Parent or guardian signature/ Firma del padre o persona custodia:
*
Date/Fecha:
*
Verbal Consent was provided over phone to referring party/Consentimiento verbal fue obtenido por teléfono:
*
Click to confirm
Message
Submit
Page load link
Go to Top