Referral (Outpatient Services)
We accept Medicaid and some commercial plans. If you do not see your plan under Insurance we unfortunately do not currently accept your insurance. If you want to be served by us we can provide you with a superbill for reimbursement to your insurance and offer you a reduced self-pay rate. You Grow Girl! serves individuals, ages 3-35, and their families within a 5-mile radius of our three locations. Please allow our team up to 5 business days to screen your request for services. You do not need your submit another referral.
What is the zip code of the individual seeking services residence/school?
*
Please Select
98004
98039
98040
98101
98102
98104
98106
98108
98109
98112
98116
98118
98119
98121
98122
98126
98134
98144
98154
98164
98174
98195
98055
98056
98057
98118
98168
98178
98188
98404
98408
98409
98418
98438
98439
98443
98444
98445
98446
98447
98499
98011
98028
98034
98103
98105
98107
98115
98117
98125
98133
98155
98177
98195
If not listed, they are outside of our service area.
Insurance
*
Please Select
None - Private Pay/Self-Pay
Ambetter (Commercial)
CHPW (Commercial: Cascade Care)
CHPW (Commercial: Cascade Select)
CHPW (Medicaid)
Coordinated Care (Medicaid)
Coordinated Care (Commercial: Cascade Select)
Molina (Medicaid) **WISe Services Only**
United Behavioral Health (Commercial)
UnitedHealthcare (Commercial: Charter)
UnitedHealthcare (Commercial: Choice)
UnitedHealthcare (Commercial: Core)
UnitedHealthcare (Medicaid)
UnitedHealthcare (Commercial: Navigate)
UnitedHealthcare (Commercial: Options)
UnitedHealthcare (Commercial: Signature Value)
UnitedHealthcare (Commercial: Select)
Wellpoint (Medicaid) **WISe Services Only**
If noy listed, they will be enrolled as self-pay.
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PROSPECTIVE PARTICIPANT
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred First Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Pronouns
*
Please Select
She/Her
They/Them
Other, Not Listed
Age
*
Please Select
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
We do not accept referrals outside of the age range
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School
*
Grade
*
Please Select
N/A
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Phone Number
*
Please enter a valid phone number.
Insurance
*
Please Select
None - Private Pay/Self-Pay
Ambetter (Commercial)
CHPW (Commercial: Cascade Care)
CHPW (Commercial: Cascade Select)
CHPW (Medicaid)
Coordinated Care (Medicaid)
Coordinated Care (Commercial: Cascade Select)
Molina (Medicaid) **WISe Services Only**
United Behavioral Health (Commercial)
UnitedHealthcare (Commercial: Charter)
UnitedHealthcare (Commercial: Choice)
UnitedHealthcare (Commercial: Core)
UnitedHealthcare (Medicaid)
UnitedHealthcare (Commercial: Navigate)
UnitedHealthcare (Commercial: Options)
UnitedHealthcare (Commercial: Signature Value)
UnitedHealthcare (Commercial: Select)
Wellpoint (Medicaid) **WISe Services Only**
Insurance ID Number
*
Write N/A if Private Pay/No Insurance
Email
*
example@example.com
Legal Guardian Full Name (required if under 13)
*
First Name
Last Name
Relationship
*
Please Select
Self Referral
Mother
Father
Sibling
Relative
Temporary Foster Parent
Social Worker
Phone Number
*
Please enter a valid phone number.
Does the individual and/or their legal guardian need an interpreter?
*
Please Select
Yes - Individual
Yes - Legal Guardian
Yes - Both
No
Preferred Language
*
Requested Service(s)
*
Individual Counseling
Family Counseling
Family Wraparound / WISe
Addiction Prevention Allyship
Is requested services court ordered?
*
Please Select
Yes
No
Unsure
Has the individual received a behavioral health diagnosis within the past 12 months?
*
Please Select
Yes
No
Unsure
REFERRAL SOURCE
Name
*
First Name
Last Name
Affiliation/Title
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Does the individual know you are making this referral?
*
Please Select
Yes
No
N/A - Self Referral
Are they willing to participate?
*
Please Select
Yes
No
Unsure
Presenting issues:
*
History of aggressive or violent behaviors
Unstable housing or homeless
History of self-harm or suicidal ideation
Experienced a traumatic life event
Anxious and/or worried about future
Lack of positive support peers/family/community
History of dating, intimate partner, or domestic violence
Have difficulty coping with challenges
Low self-esteem/worth/confidence
Alcohol and/or drug use/suspected
Select the service system(s) that are connected to the individual and/or their family.
*
None
Substance/Addiction Recovery/Rehabilitation
Court Ordered Treatment
Homeless
Special Education/504/IEP
Juvenile/Criminal Justice
Behavior Rehabilitation Services
Other Services Agency
DCYFS Foster Care / Adoption / Family Reunification
Children's Crisis Outreach Response System
Developmental Disabilities Administration
King County Superior Court: CHINS/ARY/Truancy
Other, Not Listed
Statement of concern/current circumstances about the individual
*
Location Preference for Intake Appointment
*
Please Select
In Person @ You Grow Girl! - Seattle
In Person @ You Grow Girl! - Renton
In Person @ You Grow Girl! - Tacoma
Virtual via Zoom
No Preference
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