THS Youth & Family Services Behavioral Health Referral Form
Date
-
Month
-
Day
Year
Date
Which Service Are You Seeking For this Client?
Mental Health Services
Substance Use Treatment
Both
Youth MH
Youth SUD
Client Information
Pro-Filer ID Number
Client Name
*
First Name
Last Name
Client Pronouns
He/Him/His
She/Her/Hers
They/Them/Their
Gender Identity
*
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Age
Primary Language
*
Will This Person Need an Interpreter?
*
Yes
No
SF Interpreter T/F
TRUE
FALSE
Client Phone Number
Please enter a valid phone number. If they do not have a phone number, please leave this blank.
Client Email
Please enter a valid phone number. If they do not have a phone number, please leave this blank.
Is This Person Homeless?
*
Yes
No
SF Homeless
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School District
*
School
*
Funding Source
Please Select
Medicaid/Apple Health
Medicare
Private Insurance
Self-Pay
No Insurance
Is This Court-Ordered?
*
Yes
No
SF Court-Ordered T/F
Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Pronouns
He/Him/His
She/Her/Hers
They/Them/Their
Parent/Guardian Phone Number
*
Please enter a valid phone number. If they do not have a phone number, please leave this blank.
Relationship to Youth
*
Parent
Other Family Member
Legal Guardian
Parent/Guardian Primary Language
*
Will This Person Need an Interpreter?
*
Yes
No
Referral Source Information
Your Name
*
Your Phone
*
Please enter a valid phone number.
Your Email
*
example@example.com
Please share your current referral concerns:
*
Submit
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