Referral
Intake Phone:
323-274-3075
Intake Fax:
323-967-0619
Intake Email:
intake@hillsides.org
Referral Type:
*
Please Select
School Based
Outpatient
Residential
School Name:
Referred By:
Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Client's Identifying Information:
Client Name:
*
First Name
Middle Name
Last Name
Gender:
*
D.O.B:
*
-
Month
-
Day
Year
Date
Age:
*
Primary Language:
*
Grade:
*
Race/Ethnicity:
*
Does client have Medi-Cal?
Yes
No
If yes, Medi-Cal #:
Social Security #:
Primary Caregiver Information of Client:
Client currently lives with (check all that apply):
*
Mother
Father
Guardian
Foster Parent(s)
Self
Other
Mother's Name:
First Name
Last Name
Father's Name:
First Name
Last Name
Guardian's Name:
First Name
Last Name
Foster Parent's Name:
First Name
Last Name
Other - Specify Caregiver Name:
First Name
Last Name
Caregiver's Primary Language:
*
Phone Number:
*
Please enter a valid phone number.
Alternate Phone:
*
Please enter a valid phone number.
Okay to leave message?
*
Yes
No
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Experiencing the Following (check all that apply):
Suicidal: Ideations/ Hx/ Intent/ Self Harm
Homicidal: Ideation/ Hx/ Intent
Hx of Abuse/ Trauma/ DV/ Bullying
Aggression/ Destruction of Property
Sadness/ Depressed/ Cries Often
Hallucinations (Visual, Auditory, etc)
Difficulties at School
Disruptive Behaviors
Irritability
Difficulty Concentrating
Temper Tantrum/ Mood Changes
Defiance/ Non-compliant
Impulsive/ Hyperactive/ Inattentives
Isolation/ Withdrawal
Flashbacks
Fearfulness
Nightmares
Anxious
Parent/Caregiver/ Client would like therapy to address the following concerns (Ex: Suicidal Ideation, Hyperactive, Anxious, Defiance, Difficulty Concentrating, Sadness, etc.):
Biological Mother's Name:
First Name
Last Name
Biological Father's Name:
First Name
Last Name
DMH ID#:
Who holds custody of client?
Biological Mother
Biological Father
Other
Has the client had any traumatic experiences?
*
Yes
No
Provide additional information regarding traumatic experiences:
History of Domestic Violence?
*
Yes
No
Provide additional information regarding Domestic Violence history:
DFCS Involvement:
*
Yes
No
Provide additional information regarding DCFS involvement:
Prior Episodes/Psychiatric hospitalizations/Psychiatric Hx:
*
Yes
No
Provide additional information regarding prior history:
Medical Issues (ex: asthma, diabetes, etc.)
*
Yes
No
Provide additional information regarding medical issues:
Submit
Should be Empty: