Client/Self Referral Form

Important Referral Information

This secure form is for referrals to Horizon Community Mental Health. It is not monitored continuously and must not be used for emergencies. For immediate danger, call 911. For a mental-health crisis, call or text 988 or go to the nearest emergency department. Submitting this form does not guarantee acceptance or establish a therapist-client relationship.

Client Information

First name

Last name

Date of birth

Contact Information

Phone number

Your email address

Who are you completing this referral for?

Myself Someone else

Person Completing This Form

Complete this section only if you are submitting the referral for someone else.

Full name or Agency

Relationship to client

Client email address

Reason for Referral

What would you like help with? (Select all that apply)

Anxiety or excessive worry

Depression or low mood

Trauma or PTSD

Stress or major life changes

Grief or loss

Relationship stress affecting you

Anger or irritability

Serious mental health symptoms

Other

Anything else you would like us to know? (Optional)

Briefly share any additional information that may help us understand your needs. Please do not include your complete medical or trauma history.

Insurance card — recommended. Uploading clear images of the front and back of your insurance card can help Horizon review your coverage and may prevent delays. You may submit this referral without uploading a card.

Insurance card — recommended Upload clear images of the front and back. This can help Horizon review your coverage and may prevent delays.

Add file

Please upload a file

Please enter the plan name shown on your insurance card.

What is the name of your Medicare Advantage plan?

Enter the plan name shown on your insurance card.

What plan name is shown on your insurance card?

If possible, also upload clear images of the front and back of your insurance card.

Please enter the insurance company or plan name shown on your card.

Unused upload field

Add file

Please upload a file

If possible, upload clear images of the front and back of your insurance card. This can help Horizon review your coverage and may prevent delays.

Your information will be encrypted.

Horizon Community Mental Health

Horizon Community Mental Health provides outpatient mental health services in the Antelope Valley. Services are available through in-person and telehealth appointments based on each client’s needs and eligibility.

Telephone (661) 441 - 6568
www.horizoncmh.com
626 W Lancaster Blvd, Suite 59, Lancaster, CA, 93534, United States