County/City Resources Referral Forms
California Counties provide numerous resources and support services for eligible residents. We've worked to streamline the referral process for you, providing referral forms, processes and contact information to county programs and regional centers. This county-by-county compilation provides useful information and forms for referring your clients and patients to services carved out to local Public Health Departments and Regional Centers.
Public Health
- Alpine County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Alpine County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Alpine County WIC Pediatric Referral Form (PDF)
- Alpine County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Alpine County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Amador County Baby Welcome Wagon (PDF)
- Amador County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Amador County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Amador County WIC Pediatric Referral Form (PDF)
- Amador County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Amador County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Calaveras County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Calaveras County Maternal Child Infant Public Health Nurse Referral Form (DOCX)
- Calaveras County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Calaveras County WIC Pediatric Referral Form (PDF)
- Calaveras County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Calaveras County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- City of Long Beach Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- City of Long Beach New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- City of Long Beach WIC Pediatric Referral Form (PDF)
- City of Long Beach WIC Referral for Postpartum Breastfeeding Women (PDF)
- City of Long Beach WIC Referral for Pregnant Women (PDF)
Public Health
- City of Pasadena Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- City of Pasadena New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- City of Pasadena WIC Pediatric Referral Form (PDF)
- City of Pasadena WIC Referral for Postpartum Breastfeeding Women (PDF)
- City of Pasadena WIC Referral for Pregnant Women (PDF)
Public Health
- Colusa County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Colusa County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Colusa County WIC Pediatric Referral Form (PDF)
- Colusa County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Colusa County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- El Dorado County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- El Dorado County Health Care For Children in Foster Care (HCPCFC) Foster Care Medical (Specialty) Contact Form (PDF)
- El Dorado County MCAH Public Health Nursing Interagency Referral Form (PDF)
- El Dorado County WIC Pediatric Referral Form (PDF)
- El Dorado County WIC Referral for Postpartum Breastfeeding Women (PDF)
- El Dorado County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Fresno County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Fresno County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Fresno County WIC Pediatric Referral Form (PDF)
- Fresno County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Fresno County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Glenn County Application to Determine CCS Program Eligibility (PDF)
- Glenn County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Glenn County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Glenn County Referral Packet Request for Investigation of a Private Probate Conservatorship (PDF)
- Glenn County WIC Pediatric Referral Form (PDF)
- Glenn County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Glenn County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Imperial County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Imperial County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Imperial County WIC Pediatric Referral Form (PDF)
- Imperial County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Imperial County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Inyo County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Inyo County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Inyo County WIC Pediatric Referral Form (PDF)
- Inyo County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Inyo County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Kern County Black Infant Health Program Referral Form (DOC)
- Kern County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Kern County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Kern County Perinatal Outreach Program Referral (PDF)
- Kern County WIC Pediatric Referral Form (PDF)
- Kern County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Kern County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Kings County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Kings County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Kings County Public Health Nursing Referral Form (PDF)
- Kings County WIC Pediatric Referral Form (PDF)
- Kings County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Kings County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Los Angeles County California Children's Services Fax Cover Sheet (PDF)
- Los Angeles County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Los Angeles County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Los Angeles County Nurse Family Partnership Program Confidential Referral Form (PDF)
- Los Angeles County WIC Pediatric Referral Form (PDF)
- Los Angeles County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Los Angeles County WIC Referral for Pregnant Women (PDF)
Regional Center
- Los Angeles County ELARC Early Start Intake (PDF)
- Los Angeles County ELARC Intake 3-Years and Older (PDF)
- Los Angeles County NLARC Early Start Application (PDF)
- Los Angeles County NLARC Intake Application (PDF)
- Los Angeles County Regional Center Referral Guide (PDF)
- Los Angeles County SCLARC Early Start Intake Referral Form (PDF)
- Los Angeles County Westside RC Application 3-Above (PDF)
- Los Angeles County Westside RC Intake Application 0-3 (PDF)
Public Health
- Madera County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Madera County Maternal Child Adolescent Health Referral Form (PDF)
- Madera County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Madera County WIC Pediatric Referral Form (PDF)
- Madera County WIC Program Participant Consent to Release Personal Information (PDF)
- Madera County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Madera County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Mariposa County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Mariposa County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Mariposa County WIC Pediatric Referral Form (PDF)
- Mariposa County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Mariposa County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Mono County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Mono County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Mono County WIC Pediatric Referral Form (PDF)
- Mono County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Mono County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Nevada County CHDP PM 357 Referral Form (PDF)
- Nevada County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Nevada County Health Care For Children in Foster Care (HCPCFC) Foster Care Medical (Specialty) Contact Form (PDF)
- Nevada County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Nevada County WIC Pediatric Referral Form (PDF)
- Nevada County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Nevada County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Placer County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Placer County Health Care For Children in Foster Care (HCPCFC) Foster Care Medical (Specialty) Contact Form (PDF)
- Placer County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Placer County Public Health Referral Form (PDF)
- Placer County WIC Pediatric Referral Form (PDF)
- Placer County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Placer County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Plumas County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Plumas County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Plumas County Referral for Public Health Nurse Home Visiting Services (PDF)
- Plumas County WIC Pediatric Referral Form (PDF)
- Plumas County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Plumas County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Sacramento County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Sacramento County Public Health Nursing Referral (DOC)
- Sacramento County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Sacramento County WIC Pediatric Referral Form (PDF)
- Sacramento County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Sacramento County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- San Diego County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- San Diego County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- San Diego County WIC Pediatric Referral Form (PDF)
- San Diego County WIC Referral for Postpartum Breastfeeding Women (PDF)
- San Diego County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- San Joaquin County Black Infant Health (PDF)
- San Joaquin County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- San Joaquin County MCAH Referral Form (PDF)
- San Joaquin County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- San Joaquin County WIC Pediatric Referral Form (PDF)
- San Joaquin County WIC Referral for Postpartum Breastfeeding Women (PDF)
- San Joaquin County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Sierra County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Sierra County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Sierra County Referral Form (XLSX)
- Sierra County WIC Pediatric Referral Form (PDF)
- Sierra County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Sierra County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Stanislaus County Case Management Referral (PDF)
- Stanislaus County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Stanislaus County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Stanislaus County WIC Pediatric Referral Form (PDF)
- Stanislaus County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Stanislaus County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Sutter County Child Development Behavioral Specialist Program Referral Form (PDF)
- Sutter County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Sutter County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Sutter County Public Health Referral (PDF)
- Sutter County WIC Pediatric Referral Form (PDF)
- Sutter County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Sutter County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Tehama County CHDP Confidential Referral Follow-Up Report (PDF)
- Tehama County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Tehama County Public Health Home Visiting Referral Form (doc)
- Tehama County WIC Pediatric Referral Form (PDF)
- Tehama County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Tehama County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Tulare County Child Adolescent Health Programs Car Seat Safety Program Referral (PDF)
- Tulare County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Tulare County Maternal Child Adolescent Health Programs Referral Form (PDF)
- Tulare County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Tulare County WIC Pediatric Referral Form (PDF)
- Tulare County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Tulare County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Tuolumne County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Tuolumne County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Tuolumne County WIC Pediatric Referral Form (PDF)
- Tuolumne County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Tuolumne County WIC Referral for Pregnant Women (PDF)
Regional Center
Public Health
- Yuba County Adolescent Family Life Program (PDF)
- Yuba County Child Health and Disability Prevention Program Care Coordination Follow-up Form (PDF)
- Yuba County First 5 Help Me Grow (PDF)
- Yuba County New Referral CCS/GHPP Client Service Authorization Request (SAR) (PDF)
- Yuba County WIC Pediatric Referral Form (PDF)
- Yuba County WIC Referral for Postpartum Breastfeeding Women (PDF)
- Yuba County WIC Referral for Pregnant Women (PDF)