Client/Self Referral Form

Important Referral Information

Adults age 18 and older only. 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

Email address

Person Completing This Form

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

Full name or Agency

Relationship to client

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 (Optional)

Upload clear images of the front and back of your insurance or Medi-Cal card, if available. You may submit this referral without uploading a card.

Upload insurance or Medi-Cal card

Add file

Please upload a file

Your information will be encrypted.

Horizon Community Mental Health

Horizon Community Mental Health provides individualized outpatient mental health services for adults age 18 and older 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, Lancaster, California, 93534, United States