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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
*
MM
/
DD
/
YYYY
Client Name:
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
Does the Client have a Social Security Number ?
*
Yes
No
Enter Social Security Number:
*
Does the Client have Medi-Cal ?
*
Yes
No
Enter Medi-Cal No.
*
Gender:
*
Female
Male
U.S School/Program
*
Grade
*
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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-
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UAM(New Comer/Arrival/Unaccompanied Minor)
*
Yes
No
Country of Origin:
*
Client Preferred Language
*
English
Spanish
Other
Other Language
Parent/Guardian’s/Sponsor Name :
*
First
Last
(Parent, family member, legal guardian, foster parent, placement provider, etc.)
Phone Number :
*
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-
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Parent/Guardian’s/Sponsor Address :
*
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:
###
-
###
-
####
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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