Department of Health Services

Service Request

Mental Health Service Request Form

**Although not all fields on this form are required to submit, please include as much information as possible to make the referral process more efficient. If you include an email address, you will receive a confirmation email once your referral is submitted. Fields marked with a red asterisk (*) are required.**
If this is a life-threatening emergency, please do not complete this form and go to the nearest emergency department or call 911. If you have an immediate mental health need, please do not complete this form and call 916-875-1055.

Submitter Information


You can choose to include or exclude hyphens for phone numbers. Area code is required


Client Information


Format: mm/dd/yyyy

Formats: ###-##-####
#########
###-##-###P
###-##-###Q










Caregiver Information



Presenting Problems / Risk Factors


Associated Populations (Check all that apply):

CPS Involvement (Check all that apply):


Presenting Problems (Check all that apply):


Risk Factors (Check all that apply):

* Comments Regarding Presenting Problems / Risk Factors:


Current Medications & Prescriber:

Psychiatric History / Treament History:


Additional Needs:

* Services Requested:


Reroll

**This field is case sensitive**