Glidepath Referral Form

Glidepath Referral Form
The Glidepath program at Destination Hope & Recovery offers essential benefit planning and employment support for individuals receiving or at risk of losing Housing and Essential Needs (HEN) funding. It focuses on assisting these individuals in gaining employment while navigating and understanding the impact of employment on their benefits, aiming for a balanced approach to financial independence and benefit retention..
Date

MonthDayYear
Date
Person being Referred*

First NameLast Name
DOB (Date of Birth)*

MonthDayYear
Date
County of Residence

Grays HarborPacificLewisCowlitzWahkiakumMasonThurston
Address*

Street Address (Type Homeless if Individual is Unhoused)

Street Address Line 2

CityState

Zip Code
Client/Participant Contact Information
Phone Number
Please enter a valid phone number if applicable
How can we connect with them?

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

YesNo
HEN Eligibility Letter

Please provide proof of HEN eligibility or past eligibility.
Cancelof
Letter Supporting that this individual is receiving, or has recently lost HEN funding.

This may be a letter from your agency, with their case manager attesting their eligibility.
Cancelof
FCS Supported Employment
Is the individual currently receiving, or would like to receive, FCS Supported Employment services?*

Yes, Currently ReceivingNo, Does Not Want to ReceiveUnknownWould Like to Receive
If the previous answer is yes, please put the name of the agency providing FCS Employment services:
Qualifying Risk Factor (If they would like to receive services)*

At risk for deterioration of mental illness and/or substance use disorder, including one or more of the following: persistent or chronic risk factors, such as social isolation due to a lack of family or social supports; poverty; criminal justice involvement; homelessness; care for mental illness and/or substance use disorder requiring multiple provider types, including behavioral health, primary care, long-term services and supports; or a past psychiatric history with no significant functional improvement that can be maintained without treatment and supportsDysfunction in role performance: frequently disruptive or struggling in work or school/training settings resulting in termination or suspension/expulsion; unable to work, attend school or meet other developmentally appropriate responsibilities; difficulty with daily living, communication, interpersonal skills, self-care and self-directionSubstance use treatment: has substance use disorder with two or more episodes of residential and/or inpatient treatment in the past two yearsAn inability to obtain or maintain employment resulting from age, physical disability or traumatic brain injury (must be the result of a CARE Assessment)Unable to be gainfully employed for at least 90 consecutive days due to a mental or physical impairment (must be the result of a HEN/ABD Progressive Evaluation Process)
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:

Glidepath Referral Form

Client/Participant Contact Information

Need and Eligibility Pre-Validation

FCS Supported Employment

Your Contact Information