Provider Referral Submission Portal

For assistance or help, please call 253-942-5644 or Contact Us.

Referring Provider Information

Select the Facility you are referring Client to:*
Service Requested:*
Case Manager Name*
Case Manager Phone*
Referrant (person making referral)*
Referrant Phone*
 
Referrant Email*
Referring Practice Name*
Referral Source*
Referring Practice Street Address*
Phone*
City*
State*
Zip*

Client Information

First Name*
M.I.
Last Name*
Date of Birth*
Street Address*
Phone*
City*
State*
Zip*
Email*
SSN or Last 4*
Gender*
Marital Status*
Primary Language*
 
Race/Ethnicity*
 
Current Community Mental Health Services Provider*
UDS Completed*
Suicidal Risk*
Homicidal Risk*
Parent/Legal Guardian*
Guardian Relationship*
Guardian Phone*
Emergency Contact*
Contact Relationship*
Contact Phone*
Medical Doctor*
Doctor Phone*
Psychiatrist*
Psychiatrist Phone*
Primary Payment Source*
 
Insured Name*
Insurance Policy #*
Insurance Group #*
Reason for Referral (Brief History and Chief Complaint/Presenting Problem)*
Current Medical Problems and Current Medications*


  Drag & Drop files here or click here to browse and upload.

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