Snohomish County Referral Form

Snohomish County Referral Form

Get Legal Help
In Snohomish County, LCYC provides free civil legal services to young people between ages 12-17 who are experiencing, or at risk of, housing instability. Housing instability includes, but is not limited to: homelessness, couch surfing, struggling to access emergency shelter, temporarily living with friends or family, facing eviction, or feeling unsafe/unwelcome at home.

To request legal services from LCYC's Youth Homelessness Program in Snohomish County, complete this referral form. Referrals must come from Cocoon House.
Today's date

MonthDayYear
Who needs legal services?

Cocoon House Staff Contact Information
Your name
Your email
Your phone number
Format: (000) 000-0000.

Referral Information
What is the youth's legal name?
If the youth goes by a name different than their legal name, enter below.
Enter the youth's date of birth.

MonthDayYear
What are the youth's pronouns?

Other
Please describe what the youth needs help with.
Does the youth have any concerns about their personal safety?

Youth's Contact Information
If the youth needs an interpreter, enter which language below.
What are the best ways to contact the youth?

Other
Youth's phone number
Format: (000) 000-0000.
Youth's email address
Youth's address, if available
What are the best times to contact the youth?

Referral Information
Your legal name
Your preferred name, if different from your legal name
Enter your date of birth.

MonthDayYear
What are your pronouns?

Other
Who are you working with at Cocoon House?
Please describe what you need help with.
Are you safe?

Contact Information
If you need an interpreter, enter which language below.
What are the best ways to contact you?

Other
Your phone number
Format: (000) 000-0000.
Your email address
Your address, if available
What are the best times to contact you?
Should be Empty: