FCS Referral Form

Referral Form

Foundational Community Supportive Housing and Employment
Foundational Community Supportive Services is a Medicaid selective enrolment benefit program. Destination Hope and Recovery can not guarantee approval for any individual simply based on Medicaid enrolment.
Date

MonthDayYear
Date
Referral Source*

SelfCommunity PartnerInternal Staff
ProviderOne #
Person being Referred*

First NameLast Name
DOB (Date of Birth)*

MonthDayYear
Date
County of Residence

Grays HarborPacificLewisCowlitzWahkiakumThurstonMason
Address*

Street Address (Type Homeless if Individual is Unhoused)

Street Address Line 2

CityState

Zip Code
What program are you referring the individual for, or self referring for?*

HousingEmploymentBoth
Assessment Confirmation Number(s)
Client/Participant Contact Information
Phone Number
Please enter a valid phone number if applicable
How can we connect with you/ them

Call OnlyText OnlyCall or Text Ok
Email
example@example.com
Any other information necessary to make initial contact with you/the individual?
This may be necessary if individual does not have any other valid contact information
Need and Eligibility Pre-Validation
Are you or is the individual currently enrolled in WA State Apple Health (Medicaid)*

YesNo
Qualifying Health Need*

Diagnosed with a Substance Use Disorder (SUD), as determined by meeting a 1.0 or higher on the American Society of Addiction Medicine (ASAM) CriteriaMental health need where there is a need for improvement, stabilization, or prevention of deterioration to functioning resulting from the presence of a mental illness (as determined by a licensed behavioral health agency).
Validation of Health Need

If possible, please provide proof of health need.
Cancelof
Destination Hope and Recovery is committed to ensuring the privacy of any and all Protected Health Information (PHI) disclosed to us and understands that this may include information that is protected by federal confidentiality rules (42 CFR part 2). We attest that any information provided will be protected to the extent required by any and all applicable state and federal laws. We will prohibit any further disclosure of this record unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed in this record or, is otherwise permitted by 42 CFR part 2 and/or HIPAA.
Your Contact Information

Please provide your information so we can reach out and inform you if we are able to assist the individual or need additional information.
Your Name*

First NameLast Name
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Should be Empty:

Referral Form

Client/Participant Contact Information

Need and Eligibility Pre-Validation

Your Contact Information