Referral Form

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Referral Form

Please fill out your information here. One of our staff members will get in contact with you.

* If this is a psychiatric emergency, please call 9-1-1 or go to the nearest emergency room.

If you are in crisis, please contact one of the resources below.

Free 24/7 Suicide/Crisis Hotlines

National Suicide and Crisis Line: call or text 988. Online chat option 988lifeline.org/chat.
San Mateo County Crisis Center Call 800-273-TALK (8255).
Teen Chat 4:30 PM - 9:30 PM PST Monday – Thursday
Crisis Text Line Text BAY to 741741 to reach a crisis counselor.

Your Name: *

Your Email: *

Your Phone Number: *

Name of your organization: *

Are you contacting ACS for yourself, or on behalf of someone else? *

Myself

Someone else

Other:

Potential client's name:

Potential client's age (if applicable):

Potential client's pronouns (if applicable):

Potential client's parent/guardian's name:

Potential client's parent/guardian's contact info:

What program are you interested in? *

Community Counseling

Adolescent Substance Addiction Treatment

Outlet

I don't know

Required

Services that you're interested in: *

Mental health counseling

Parent support

Substance addiction treatment

Social support groups

Clinical support groups

Parent/caregiver support groups

Educational workshops

I don't know

Other:

Required

Reason for referral:

Anything else we should know?

Submit

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