Horizons Outpatient MH & CM Services Referral Form

This referral form is not for crisis emergencies.
If this is an emergency and the youth's life is in imminent danger, please contact 911.

Additionally, the following entities can be contacted in case of a crisis situation:
Psychiatric Emergency Services: (415) 206-8125
Comprehensive Child Crisis: (415) 970-3800
SF Mobile Crisis Team (age 18 and up): (415) 255-3737 
Seneca Mobile Response Team: 877-305-8989
S.F. Suicide Prevention: (415) 781-0500
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This is a confidential online referral form for Mental Health case management & therapeutic services for Transitional Aged Youth (TAY) ages 16-24 provided by Horizon's Outpatient Treatment Program. 

If a youth is struggling with substance use, the city of San Francisco offers substance use treatment services. To be eligible for services, 
  • Youth must be under 21 years of age
  • Targeted for Medi-Cal or uninsured. Cannot have private insurance that covers SUD treatment.
  • Resident of San Francisco
Referrals can be made using these links SUD Treatment Referral- English or  Referencia para tratamiento SUD


If youth is in the foster care system, the social worker will first need to contact Foster Care Mental Health (FCMH) at 415-970-3877 to start the referral process


Once a referral is received, please expect a response within 24-48 hours to further discuss the referral and determine appropriateness of services. 

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If you have any questions, please contact Gabriela Espinoza, Outpatient Program Manager, at gespinoza@horizons-sf.org or 415-756-1851

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Referral Source- Name & Title or Relationship to Youth *
Referral Source- Phone *
Referral Source- Email
Youth First Name *
Youth Chosen/ Preferred Name *
Youth Last Name *
Youth Phone Number *
Youth Email (for Telehealth / Virtual Meeting Purposes)
Youth Preferred Language of Service *
Is the client aware of this referral. *
Required
Date of Birth *
MM
/
DD
/
YYYY
Age *
If under 18, who is their Parent/ Guardian? Are they involved with treatment or services for youth. *
Service of Primary Interest *
Service of Secondary Interest *
Reason for Referral
Clear selection
Family/ Home: With whom does the client live?
Clear selection
Strengths: What are client’s strengths or interests? (what do they enjoy doing? favorite food? hobbies? games? media?)
Mental Health: Is the youth seeking support for this service?
Clear selection
Mental Health: Does the youth engage in harmful behavior towards themselves or others?
Clear selection
Education: Is the youth in school?
Clear selection
Counseling/Therapy: Has this youth ever received counseling or therapy?
Clear selection
System- Involvement: Is the youth currently system involved? (If parent, answer for youth)
Clear selection
Additional information relevant to referral.
Submit
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