CAC Referral Form

Child/Youth Information:

Kids' Mental Health Pierce County
Child/Youth Name

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child/Youth Address
Child/Youth Phone

Area CodePhone Number
Is it okay to leave a voicemail at this number?
Child/Youth Email
example@example.com
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone

Area CodePhone Number
Parent/Guardian Email
example@example.com
Insurance Provider:
Provider One or Subscriber Number
Company Name:
(Example: Regence, Tricare, etc.)
Tribal Connection
Juvenile Justice Involvement
Department of Children, Youth and Families (DCYF) Involvement:
Special Education
Enrolled in Developmental Disabilities Administration (DDA):
In Utero Substance Exposure:
Intellectual or Developmental Disability:
Adoption Status
Age of Onset of Symptoms
I would like to consult with the Team About:

Other
Referent Information:
Name of Person Making the Referral

First NameLast Name
Name of Clinic / Hospital / Organization*
Phone Number

Area CodePhone Number
Referent Email
example@example.com
Reason for Referral:
Briefly, provide information as to reason for referral and expected outcomes
To maintain the privacy of youth and family a release of information (ROI) is required. A Release of Information is required to be signed by youth over the age of 13. Do you currently have a signed Release of Information (ROI)?
A RELEASE OF INFORMATION form should accompany each referral request.
How did you hear about Kids’ Mental Health Pierce County?

Other
If you have additional questions please contact: Vanessa Adams vanessa.adams@multicare.org
Should be Empty:

Child/Youth Information:

Referent Information: