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
Please check the box below if it's statement applies to you.

HopeSparks Behavioral Health Services provides crucial and preventive behavioral healthcare for children and their families. With a focus on the pediatric population (age 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.
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.
Pierce County Early Childhood Network

Do you live in Pierce County and have children 0-5 years of age?
Relatives Raising Children

Do you live in Pierce County and are you a relative caregiver for a child age 0-18 years old?
Readiness to Learn Tacoma School District

Do you have children K-12 attending any Tacoma District School?
Readiness to Learn Puyallup School District

Do you have children K-12 attending any Puyallup School District?
Care Connect COVID WA

Have you recently (less than two weeks) tested positive for COVID-19?
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