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AMANECER ADULT 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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Name of Referring Person
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First
Last
Phone # of Referring Person
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Email of Referring Person
Referring Person’s Title & Referring Agency
Client Name:
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First
Last
Date of Birth
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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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Address :
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Street Address
City
State / Province / Region
Postal / Zip Code
Phone Number
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Alternate Phone Number
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Gender:
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Female
Male
Country of Origin:
Preferred Language
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English
Spanish
Other
Other Language
Email
Please Check
DCFS Involvement
Probation
Court Ordered
Other (Please provide name in the comment section)
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