Assessment Referrals Matrix

Support for Families of Children with Disabilities, in collaboration with 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.

Assessment Referrals Matrix (View as PDF)

Know what you are looking for? Jump to CCS, CPMC, DPH, MDAC, GGRC,

SFUSD early start, SFUSD preschool, SFUSD TK-12, SFUSD private placement

California Children’s Services (CCS) 30 Van Ness, Suite 210, San Francisco CA 94102 T: 415-575-5700 F: 415-575-5790 San Francisco Website \| California Website
Category		Ages	Insurance		Language		Timeline
Medical conditions covered by CCS		0-21	N/A (eligibility based on financial or other need)		English Spanish Cantonese Mandarin Korean Tagalog		60 days (A+T)

Referral Process
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 -insurance info		General consent form

California Pacific Medical Center (CPMC) 1625 Van Ness, 3rd Floor San Francisco, CA 94107 T: 415-600-6200 F: 415-749-1433 Website
Category		Ages	Insurance		Language		Timeline
Has or at risk for developmental delays or disabilities, or medical concerns		0-18	FSM SFHP HK Uninsured		English Spanish		60 days (A)

Referral Process
Referral	Medical Info Needed			Family/Parent Docs		Consent Form
Parent calls to start intake process				-Insurance info -CPMC Questionnaire packet		General consent form

Department of Public Health: Community Behavioral Health Services (CBHS) 1380 Howard St, 1^st Floor San Francisco, CA 94103 T:415-255-3737 F: 415-255-3629 Website
Category		Ages	Insurance		Language		Timeline
Mental health or behavioral needs		0-18	FSM SFHP HK Uninsured		All languages		10 days (A+T)

Referral Process
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			-insurance 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 T:415-206-6129 F: 415-206-6302 [email protected] Website
Category		Ages	Insurance		Language		Timeline
Developmental or behavioral concerns, including: Gross/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 insurance N/A 6-18 insurance required	FSM SFHP BC HK		English Spanish		60 days (A)

Referral Process
Referral	Medical Info Needed			Family/Parent Docs		Consent Form
Primary Care Provider emails or faxes MDAC Referral Form [pdf] to start intake process	copies of previous assessments if available			-proof of residency -insurance info (if 6-18)		General consent form

Golden Gate Regional Center (GGRC) 1355 Market St, #220 San Francisco, CA 94103 T:888-339-3305 F: 888-339-3306 [email protected] Website
Category			Ages	Insurance	Language		Timeline
Development delay in 1 or more areas; or an established risk condition			0-3	FSM SFHP BC HK Uninsured	English Spanish Cantonese Mandarin		45 days (A+T)

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 (A+T)

Referral Process
Referral 0-3	Medical Info Needed	Family/Parent Docs				Consent Form
Provider emails or faxes Early Start Referral Form [pdf], or parent emails or faxes Early Start Intake Form [doc] to start intake process	Medical/ Develop-mental Reports
Referral 3+	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

San Francisco Unified School District (SFUSD) Early Childhood Special Education Services (Early Start) * 1520 Oakdale Ave, Ground Floor San Francisco, CA 94124 T: 415-401-2525 F: 415-920-5075 Website
Category	Ages		Insurance		Language	Timeline
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 (A + T)

Referral Process
Referral		Medical Info Needed		Family/Parent Docs			Consent Form
Typically referred by GGRC or child’s doctor. Child may 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 1520 Oakdale Ave, Ground Floor San Francisco, CA 94124 T: 415-401-2525 F: 415-920-5075 [email protected] Website
Category	Ages		Insurance		Language	Timeline
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 (A+T)

Referral Process
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 (Proof of Residency, Birth Certificate, hearing/vision screening results if available)			Included in PreK SpEd Referral Packet

San Francisco Unified School District (SFUSD) Enrolled in TK/K through 12 with SFUSD Depends on School Site of Attendance T: 415-759-2206 F: 415-242-2528 Website
Category	Ages		Insurance		Language	Timeline
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 (A+T)

Referral Process
Referral		Medical Info Needed		Family/Parent Docs			Consent Form
Parent or provider submits detailed letter with request for assessment to the 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 [doc] Chinese [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 T: 415-759-2206 F: 415-242-2528 Website
Category	Ages		Insurance		Language	Timeline
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 (A+T)

Referral Process
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. proof of Residency and Birth Certificate)			Included in Private/Parochial Referral Packet