Submit a referral form

Our team will follow up within 2 business days

Are you a social worker, healthcare provider, case manager, or community advocate working with someone who needs mental health support? Use our referral form to connect your client with the right services.

Casa de la Familia Referral Form

PDF form to be completed by the referring provider or advocate and submitted by email.

FORMAT
PDF - fillable

SUBMIT TO
aaa@casadelafamilia.org

Download Referral Form (PDF)

HOW IT WORKS

Three steps to submit a referral

The process is simple and takes just a few minutes. Once we receive your form, our intake team will reach out to the client directly within one business day.

Download the form

Click the download button above to get the fillable PDF referral form. It's available in both English and Spanish.

Tip: Open the PDF in Adobe Acrobat or your browser to fill it in digitally.

Complete the form

Fill in the client's contact information, the service you're referring them for, and your contact details as the referring provider.

Fields include: client name, service needed, referral reason, and your agency or organization name.

Send it to us

Email the completed form to our intake team. We'll confirm receipt and follow up with the client within one business day.

Send to: DCovarrubias@casadelafamilia.org
Subject: Referral [Client Last Name]

Questions about the referral process?

Our intake team is happy to walk you through the process or answer anyquestions about the services we can provide for your clients.

Call (877) 611-2272

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