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Let's See What You May Qualify For

Not sure where to start? To help you find out, answer a few questions about your household, income, and needs. This usually takes about 2 minutes.

Note: This questionnaire is for screening/navigation only; it does not replace an official eligibility determination for benefits.

CBS Refer A Client Form

Medi-Cal / CalFresh / Health Access Program (HAP)

Do not include Social Security Numbers on this form.

  1. Referral Source
  1. Client Referral Information
  1. Program Requested
Select all that apply
  1. Client Indentifying Information
Date of Birth
Month
Day
Year
Gender
Housing Situation
Us citizen
Yes
No
Marital Status
Single
Married
Divorced
Background
  1. Documents You May Be Required to Provide

This list is for reference only. Depending on the program, clients may be asked to provide certain documents. You do not need to submit these documents at this time. CBS will advise you of the specific documents required for your selected program.


Proof of Identity

  • Driver's licence or State ID

  • Permanent Resident Card (both sides) or U.S. Passport

  • Social Security Number (SSN), if requested


Proof of Income

  • Paystubs from the past 30 days

  • Award letter (unemployment, disability, Social Security)

  • Child support check

  • Bank statement

  • Retirement or pension statement

  • Vehicle registration


Proof of Expenses

  • Rental agreement or rent receipt

  • Mortgage bill

  • Motel receipt

  • Utility bill

  1. Additional Caseworker Comments

Have Questions?

We're here to help. Reach out to our team of experts and we'll make sure you get the information and support you need.

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