Referral Form

Referral for Behavioral Health Services

Parents, school districts, and teachers may complete and submit the initial referral for behavioral health services to determine program eligibility for a child/student. A Desert/Mountain Children's Center representative will contact the referring individual within 24 hours of receiving the referral form. Additional information regarding the specific types of programs and services offered can be made available by contacting our office at (760) 955-3601 or e-mail them at

Initial Referral Form

Referred by: 

 Desert Mountain Children's Center logo

Contact Number: 


E-mail of Referring Individual: 


Child Name: 


Child Grade: 


Child DOB: (MM/DD/YYYY) 


 Child Age: 



Home Phone: Work Phone: 

Mailing Address: 

City: Zip Code: 

 IEP or Transfer in IEP?: 


Insurance Information

Please mark the appropriate insurance provider for the child/student.

 Pacific Care 

 IEHP Tri Care  Molina  Cash PayMedi-Cal Eligible?Yes No

Consent Information

Consent to Exchange Confidential/Privilege Information


I authorize  and the Desert/Mountain Children's Center to exchange confidential/privileged information,


including information regarding mental health treatment, in order to develop and implement a service plan for .


 By marking this box, the Caregiver/Legal Guardian is aware and gives permission for this mental health referral.

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