THS Youth & Family Services Behavioral Health Referral Form
Date
-
Month
-
Day
Year
Date
Please Indicate Your Relation to This Referral
I am a THS employee seeking to refer an existing client into Youth & Family Services
I am a provider who is seeking to refer someone into Youth & Family Services at Therapeutic Health Services
Which Service Are You Seeking For this Client?
Mental Health Services
Substance Use Treatment
Both
Client Information
Pro-Filer ID Number
*
Client Name
*
First Name
Last Name
Client Pronouns
She
He
They
Other
Gender Identity
*
Client Date of Birth
*
-
Month
-
Day
Year
Date
Is this Patient Less Than 13 Years Old?
*
Yes
No
Primary Language
*
Will This Person Need an Interpreter?
*
Yes
No
Client Phone Number
*
Please enter a valid phone number. If they do not have a phone number, please leave this blank.
Can This Person Receive Messages?
*
Yes
No
Is This Person Seeking Couples or Family Therapy?
*
Yes
No
Please list the names of anyone who will be participating in couples or family and indicate their relationship to the client
*
Is This Person Homeless?
*
Yes
No
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School District
*
School
*
Branch
*
Please Select
Eastside
Everett
Kent
Rainier
Seneca
Shoreline
Summit
YFS-Seattle
YFS-Everett
Funding Source
*
Please Select
Medicaid/Apple Health
Medicare
Private Insurance
Self-Pay
Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Pronouns
She
He
They
Other
Parent/Guardian's Relationship to Client
*
Parent/Guardian Phone Number
*
Please enter a valid phone number. If they do not have a phone number, please leave this blank.
Can This Person Receive Messages?
*
Yes
No
Primary Language
*
Will This Person Need an Interpreter?
*
Yes
No
Referral Source Information
Your Name
*
First Name
Last Name
Your Phone Number or Extension
*
Please enter a valid phone number.
Can You Receive Messages?
*
Yes
No
Your Email
*
example@example.com
Are You This Client's Provider?
*
Yes
No
Your Agency
*
Your Role In Agency
*
Do You Want To Receive Updates Regarding the Referral and Intake?
*
Yes
No
Please share your current referral concerns:
Submit
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