PROSPECTIVE PARTICIPANT (YOUTH)
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred First Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Pronouns
*
Please Select
She/Her
He/Him
They/Them
Other, Not Listed
Age
*
Please Select
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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.
Format: (000) 000-0000.
Apple Health / Medicaid Insurance
*
Please Select
CHPW
Coordinated Care
Molina
UnitedHealthcare
Wellpoint
ProviderOne Number
*
Email
*
example@example.com
Legal Guardian Full Name
*
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.
Format: (000) 000-0000.
Does the family need an interpreter?
*
Please Select
Yes - Child/Youth
Yes - Legal Guardian
Yes - Both
No
Preferred Language
*
Is your request for family services court ordered?
*
Please Select
Yes
No
Unsure
Has anyone in the family received a behavioral health diagnosis in the past 12 months?
*
Please Select
Yes - Child/Youth
Yes - Parent/Guardian
Yes - Child/Youth & Parent/Guardian
No
Unsure
REFERRAL SOURCE
Name
*
First Name
Last Name
Affiliation/Title
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Does the family 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 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 family:
*
Submit
Should be Empty: