Children's Council of San Francisco - Child Care Referral Form

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Please complete this form to refer families to Children's Council for child care services and resources. After your submission, a member of our Resource and Referral team will contact the family within two business days.

Questions? Please reach out to our team at outreach@childrenscouncil.org

This Information is about the staff member who is referring this family to Children's Council

First Name

Last Name

Email

Phone Number

Organization

Other

Your Title

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Parent First Name

Parent Last Name

Parent/Guarding Preferred Language

Parent/Guardian Phone Number

Parent/Guardian Email:

Parent/Guardian Street Address (include apt #)

City

Zip Code

What service(s) is the family seeking?

Help paying for child care

Become a licensed child care provider

Other services sought

Please be advised: Parents currently receiving CalWORKs cash aid, or who received it within the past 24 months, should contact their CalWORKs specialist to request child care when they submit this form. If eligible, the specialist will send the referral directly to Children's Council. If the family needs assistance in reaching out to their CalWORKs worker, please provide their name, phone number, and email address below.

CalWORKS Brochure: https://www.childrenscouncil.org/wp-content/uploads/2026/05/2026-CalWorks-Brochure-EN_Web.pdf

Please share any additional information about the family that is important for us to know

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Child Details (to add additional children, click "Add another..." at the bottom of the page)

Child's First Name

Child's Last Name

Child's Date of Birth

Has the child been diagnosed with Special Need (IFSP/IEP)?

YesNo

Does the family have any concerns about the child's development?

YesNo

Does the child have an open CPS case?

YesNo