Horizons Outpatient Mental Health & Case Management 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 youth and young adults ages 10-24 and their families provided by Horizon's Behavioral Health Team. 

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 Celina Lucero at clucero@horizons-sf.org, or at (415) 310-8777.


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Referral Source Name & Title or Relationship to Youth/Nombre/título y relación de la persona referiendo al individual

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Referral Source Phone Number/Numero de telefono de la persona referido al individual

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Referral Source Email/Correo electrónico de la persona referido al individual

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Individual's First Name/Primer nombre del individual

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Individual's chosen/preferred name/Nombre al que el individual usa para referirse


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Individual's last name/Apodo del individuo


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Individual’s phone number/Numero de telefono para el individuo


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Individual’s email/Correo electronico del individuo


Individual’s preferred language/Idioma primario del individuo


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Is the individual aware of referral (single choice)/Está consciente el individuo de la referencia a nuestros servicios


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Required

Individual’s date of birth/Fecha de nacimiento del individuo


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MM
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DD
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YYYY

Individual’s age/Edad del individuo

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If under 18, who is their parent/guardian? Please include contact information and confirm if they are aware of this referral. (In california an individual age 12 and over are able to consent for counseling/therapy services without guardian if minor is mature, child of incest, and or present a danger of serious physical or mental harm to self or others without treatment).


Si el individuale es menor de 18, ¿quiénes son los guardianes? Por Favor incluye información para contactar y confirmar si están consiente de la referencia. (En California, si el joven tiene 12 o mas años, podran dar consentimiento a servicios para consejería/terapia si el/la menor es suficientemente maduro, producto de incest, y/o presenta un peligro físico o mental si es que no recibe tratamiento) 

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Service of interest/Servicio de interes

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Reason for Referral/Motivo de la remisión
Clear selection

Family/Home: with whom does the individual live?/Familia/Hogar: ¿con quién vive el cliente?

Clear selection

Mental health: does the individual engage in harmful behavior towards themselves or others?/Salud mental: ¿el individuo tiene conductas dañinas hacia sí mismo o hacia los demás? 


Clear selection

Education: is the individual in school?/Educación: ¿está el joven en la escuela?

Clear selection

Are they currently receiving counseling/therapy?/¿Están recibiendo servicios de terapia o consejería?

Clear selection

Additional information relevant to referral/Información adicional relevante:

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