`
 

Assessment Referrals Matrix

Support for Families of Children with Disabilities, in collaboration with the High Risk Infant Interagency Council (now Help Me Grow) and the Child Health Disability Prevention Program (CHDP), have developed this matrix to gather assessment information all in one place. We hope you find this resource helpful and invite you to contact us with questions or comments.

 
 

California Children's Services (CCS)

30 Van Ness, Ste 210,
San Francisco CA 94102

Website

T: 415-575-5700
F: 415-575-5790

Category

Ages

Insurance

Language

Timeline

A

A+T

Referral Process

Medical conditions covered by CCS

0-21

N/A

(eligibility based on financial or other need, see CCS More Info )

English
Spanish
Cantonese
Mandarin

Korean
Tagalog

60 days

x

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

Provider mails or faxes CCS Referral Form [pdf], or parent mails or faxes CCS Application Form [pdf]

Detailed medical reports

- CCS Application Form [pdf]
-proof of residence
-income documentation
-ins info

General consent form

California Pacific Medical Center (CPMC)

1625 Van Ness, 3rd Flr
San Francisco, CA 94107
Website

T: 415-600-6200
F: 415-749-1433

Category

Ages

Insurance

Language

Timeline

A

A+T

Referral Process

Has or at risk for developmental delays or disabilities, or medical concerns

0-18

FSM
SFHP
BC
HK

English
Spanish

60 days

X

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

Parent calls to start intake process

-Insurance info
-CPMC Questionairre packet

General consent form

Department of Public Health: Community Behavioral Health Services (CBHS)

1380 Howard St, 1st Flr
San Francisco, CA 94103

Website

T:415-255-3737
F: 415-255-3629

Category

Ages

Insurance

Language

Timeline

A

A+T

Referral Process

Mental health or behavioral needs

0-18

FSM
SFHP
HK

Uninsured

All languages

10 days

x

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

Parent calls central access number or walks in to any civil service clinic to start intake process

Detailed medical reports

-ins info for SM, SFHP, HK
-proof of residency

Multidisciplinary Assessment Center (MDAC): SF General Hospital, UCSF Department of Pediatrics

1001 Potrero Ave, MS 6E (mailing address)
Main Hospital Building, 6B (physical location)
San Francisco, CA 94110

Website

T:415-206-6129
F: 415-206-6302
mandac-dyj@ sfghpeds.ucsf.edu

Category

Ages

Insurance

Language

Timeline

A

A+T

Referral Process

Developmental or behavioral concerns, including:

  • Gross or Fine Motor Delays
  • Speech/Language
  • Social Development
  • Atypical Behaviors
  • Learning or Cognitive Problems
  • Behavioral Problems
  • Aggressive Behaviors
  • Chronic Illness or Genetic Condition
  • ADHD

0-5 (ins N/A)

6-18 (ins req’d)

FSM
SFHP
BC
HK

English
Spanish

60 days

X

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

Primary Care Povider emails or faxes MDAC Referral Form [pdf] to start intake process

copies of previous assessments if available

-proof of residency
-ins info (if 6-18)

General consent form

Golden Gate Regional Center (GGRC)

1355 Market St, #220
San Francisco, CA 94103

Website

T:888-339-3305
F: 888-339-3306
intake@ggrc.org

Category

Ages

Insurance

Language

Timeline

A

A+T

Referral Process

Development delay in 1 or more areas; or an established risk condition

0-3

FSM
SFHP
BC
HK
Uninsured

Eng
Span
Cant
Mand

45 days

X

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

Provider emails or faxes Early Start Referral Form [doc], or parent emails or faxes Early Start Intake Form [doc] to start intake process

Medical/
Develop-mental
Reports

GGRC Auth for Use of Protected Information (HIPAA) [pdf]

Developmental disability defined as:

· Intellectual Disability (or closely related condition)

  • Cerebral Palsy
  • Epilepsy
  • Autism

3+

FSM
SFHP
BC
HK

Uninsured

English
Spanish
Cantonese
Mandarin

120 days

x

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

Parent calls intake line to start intake process

(If you are a provider, call intake line with parents to initiate the process )

Relevant Medical Reports

GGRC Auth for Use of Protected Information (HIPAA) [pdf]

San Francisco Unified School District (SFUSD)

Early Childhood Special Education Services (Early Start) *
1520 Oakdale Ave, Ground Flr
San Francisco, CA 94124

Website

T: 415-401-2525
F: 415-920-5075

Category

Ages

Insurance

Language

Timeline

A

A+T

Referral Process

Solely low incidence disability:

  • Hearing Impairment
  • Vision Impairment
  • Severe Orthopedic Impairment
  • or a combination thereof

0-3

N/A

English
Spanish
Cantonese
Mandarin

45 days

x

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

Typically referred by GGRC or child’s doctor. Child chay also be referred by parent.

Medical Report indicating solely low incidence disability

proof of residency

SFUSD Authorization to Release Information
English [pdf]

Spanish [pdf]

San Francisco Unified School District (SFUSD)
Special Education

Attn: Prekindergarten Intake Unit
3045 Santiago Street
San Francisco CA 94116

Website

T: 415-759-2214
F: 415-242-2528

Category

Ages

Insurance

Language

Timeline

A

A+T

Referral Process

  • Autism
  • Deaf-blindness
  • Deafness
  • Emotional Disturbance
  • Hearing Impairment
  • Intellectual Disability
  • Multiple Disabilities
  • Orthopedic Impairment
  • Other Health Impairment
  • Specific Learning Disabilities
  • Speech and Language Impairment
  • Traumatic Brain Injury
  • Visual Impairment
  • Established Medical Disability

3-5

N/A

English
Spanish
Cantonese
Mandarin

15 days to respond to referral

X

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

PreK SpEd Referral Packet
English [pdf]
Spanish [pdf]
Chinese [pdf]
Vietnamese [pdf]

Family/parent sends docs directly to Pre-K Unit (SFCD can help parents fill out)

Any pertinent medical reports are requested, but not required unless child has a vision impairment.

Parents must send in a completed intake packet with supporting documents (e.g. 2 Proofs of Residency,Birth Cert., hearing/vision screening results if available)

Included in PreK SpEd Referral Packet

Enrolled in TK/K through 12 with SFUSD
Depends on School Site of Attendance

Website

T: 415-759-2206
F: 415-242-2528

Category

Ages

Insurance

Language

Timeline

A

A+T

Referral Process

  • Autism
  • Deaf-blindness
  • Deafness
  • Emotional Disturbance
  • Hearing Impairment
  • Intellectual Disability
  • Multiple Disabilities
  • Orthopedic Impairment
  • Other Health Impairment
  • Specific Learning Disabilities
  • Speech and Language Impairment
  • Traumatic Brain Injury
  • Visual Impairment

5-22

N/A

English
Spanish
Cantonese

Mandarin
Vietnamese

15 days to respond to referral

x

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

Parent or provider submits detailed letter with request for assessment to child's SFUSD school site.

Sample Request for Assessment Letter
English [doc]

Any pertinent medical reports are requested, but not required.

N/A

SFUSD Authorization to Release Information Form, if applicable

English [pdf]

Spanish [pdf]

Private, Parochial Elementary, Middle, or High School OR Home-Schooled)

Screening and Assessment Center (Central Office) *
3045 Santiago St
San Francisco, CA 94116

Website

T: 415-759-2206
F: 415-242-2528

Category

Ages

Insurance

Language

Timeline

A

A+T

Referral Process

  • Autism
  • Deaf-blindness
  • Deafness
  • Emotional Disturbance
  • Hearing Impairment
  • Intellectual Disability
  • Multiple Disabilities
  • Orthopedic Impairment
  • Other Health Impairment
  • Specific Learning Disabilities
  • Speech and Language Impairment
  • Traumatic Brain Injury
  • Visual Impairment

5-22

N/A

English
Spanish
Cantonese

Mandarin

15 days to respond to referral

x

Referral

Medical Info Needed

Family/Parent Docs

Consent Form

Private/Parochial Referral Packet

English [pdf]
Spanish [pdf]

and family/parent sends docs directly to Private/Parochial Assessment Unit (SFCD can help parents fill out)

Any pertinent medical reports are requested, but not required.

Parents must send in a completed referral packet with supporting documents (e.g. 2 Proofs of Residency and Birth Cert.)

Included in Private/Parochial Referral Packet