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AMANECER CHILDREN INTAKE REFERRAL
Amanecer Community Counseling Service
Questions/Concerns: Contact the Intake Specialist at 213-416-1106.
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DATE OF REFERRAL
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MM
/
DD
/
YYYY
Client Name:
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First
Last
Date of Birth
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MM
/
DD
/
YYYY
Does the Client have a Social Security Number ?
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Yes
No
Enter Social Security Number:
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Does the Client have Medi-Cal ?
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Yes
No
Enter Medi-Cal No.
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Gender:
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Female
Male
U.S School/Program
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Grade
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Please select
Day Care
Pre-Kindergarten
Transitional Kindergarten
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Unknown
Phone Number
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UAM(New Comer/Arrival/Unaccompanied Minor)
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Yes
No
Country of Origin:
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Client Preferred Language
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English
Spanish
Other
Other Language
Parent/Guardian’s/Sponsor Name :
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First
Last
(Parent, family member, legal guardian, foster parent, placement provider, etc.)
Phone Number :
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Parent/Guardian’s/Sponsor Address :
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Street Address
City
State / Province / Region
Postal / Zip Code
Parent/Guardian’s/Sponsor Preferred Language
*
English
Spanish
Other
Other Language
Parent/Guardian’s/Sponsor Email
Name of Referring Person:
First
Last
Phone # of Referring Person:
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Email of Referring Person
Referring Person’s Title & Referring Agency:
Please CHECK
DCFS Involvement
Probation
Other (Please provide name in the comment section)
DCFS officer name
First
Last
DCFS officer Phone
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