Agency Referral Form

Agency Referral Form

Upon Completion of this form, HopeSparks will be able to refer you to the program that will best serve your needs or we will provide you with information to hopefully connect you with services elsewhere.
If you are experiencing a mental health emergency, please call 988.

If you are in need of additional resources, please call 211.
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email*
example@example.com
Mailing Address (or just the zip code you reside in)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Release of Information Authorization*

I authorize the release to and the obtaining of information to HopeSparks for one or more of the programs listed below in the Programs section.
Programs

HopeSparks Family Services available programs please check ALL that apply to you or the child you are calling for.
Behavioral Health Services
HopeSparks Behavioral Health Services provides crucial and preventive behavioral healthcare for children and their families. With a focus on the pediatric population (3 to 21), we work to remove barriers and stigma by providing evidence-based treatments that help families manage their lives with reduced symptoms and less stress. Due to capacity limitations we are unable to accept online referral forms at this time. Comprehensive Life Resources takes walk-ins for children and families in Pierce County Monday-Thursday 8am-3:30pm at this location: 1305 Tacoma Ave. S Tacoma, WA 98402. You can find more information on how to get connected to services HERE. You may be able to connect to services through Seattle Children's Mental Health Referral Service you can also submit an online referral HERE.
Children's Developmental Services

Please select all that apply below.
Do you have a child(ren) who is 0-3 years old? (must be no more than 45 days away from their 3rd birthday)
Do you reside in the Steilacoom, University Place, Peninsula, Clover Park, or Tacoma school district?
Children’s Developmental Services provides early intervention for children from birth to three years old. A developmental assessment is used to evaluate each child’s individual strengths and needs to determine eligibility for services. If your child is found eligible, our Early Intervention Team will provide comprehensive services.
Family Support Services

Please select all that apply below. Hover over an option to learn more about their respective program.
Relatives Raising Children

Do you live in Pierce County and are you a relative caregiver for a child age 0-18 years old? (Example: Grandparent raising a grandchild, aunt/uncle raising a niece/nephew or an older sibling raising a younger sibling). Are you interested in getting connected with a Kinship Navigator that can help provide you and your family with resources and support services?
Readiness to Learn

Do you have children (K-5) who attend school in the Tacoma or Puyallup school district? Are you interested in receiving ongoing case management (bi-monthly appointments), taking a strengths based assessment, and creating an individualized family plan with the intent of working on barriers to your child’s success in school? The outcome goals of this program aim to improve attendance, behavior and academic success.
Pierce County Early Childhood Network

Do you live in Pierce County and have children 0-5 years of age? Are you interested in getting connected to diaper bank information and other resources? Please contact Rosario Bautista Gonzalez directly at: (253) 290-1478 or rbautista@hopesparks.org. You can also get more information here: https://www.pcecn.org
Care Connect COVID WA

Have you recently (in the last two weeks) tested positive for COVID-19? If yes, you can get connected to the Care Connect COVID-19 program through the Department of Health. This program can help with Fresh food orders, shelf stable food and care kit delivery to your home. Please call the DOH COVID Hotline: 1-800-525-0127, option # to get connected.
Are you a returning client?

YesNo
Your referral will be sent to all programs you qualify for.

In addition, once you become an active HopeSparks client you will receive access to HopesCloset for basic needs including clothing, some household items and diapers.

If you did not qualify for any HopeSparks programs, please contact 211 for more information on resources that you may qualify for.
Should be Empty:

Agency Referral Form

Personal Information

Programs

Behavioral Health Services

Children's Developmental Services

Family Support Services