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Lutheran Community Services – WISe Referral
Youth MUST have an Active Provider One # (Medicaid/Apple Health)
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Email
*
Your email
Name of Youth
*
Your answer
Date of Birth
*
Your answer
Age
*
Your answer
Gender
*
Your answer
Ethnicity
*
Your answer
Address
*
Your answer
County
*
King
Snohomish
Youth Lives With
*
Biological Family
Adopted Family
Foster Care (supervised)
BRS
VPS
Other:
MCO
*
Wellpoint Washington (previously Amerigroup)
Molina
CHPW (Community Health Plan of Washington)
Coordinated Care
UHC (UnitedHealthcare Community Plan)
Provider One # (REQUIRED FOR ENROLLMENT)
*
Your answer
Preferred Language
*
Your answer
Caregiver Name & Relationship
*
Your answer
Legal Guardian?
*
Yes
No
Caregiver Phone
*
Your answer
Caregiver Email
*
Your answer
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