Adult Behavioral Health Services Referral Form

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Please fill out as much information as you can when making a referral, this will help WAPI Community Service Staff to serve the youth. Thank you!

Email *

WAPI Community Services Adult Behavioral Health Services Referral Form

| 861 Poplar Pl. S., Seattle, WA 98144 | 28815 Pacific Hwy S. Suite 7A , Federal Way , WA 98003 | Office: 844.987.9274 | Fax: 206.838.1851 | Website: wapiseattle.org |

HIPAA Notification

This referral form is for the sole use of the intended recipient(s). The information in this referral form, including attachments, may be confidential and/or legally privileged and may contain protected health information. If you believe that it has been sent to you in error, please notify WAPI Community Services (WAPI) at referrals@wapiseattle.org and delete the message and all its attachments. Any disclosure, copying, distribution or use of this information by someone other than the intended recipient is strictly prohibited.

Today's Date *

YYYY

Type of Service(s) *

Substance Use Disorder (SUD) Assessment and Treatment Services

DUI Assessment*

Required

*DUI assessment requirements

Per Washington Administrative Code (WAC) 246-341-0820, a DUI assessment is required to be in-person. The following are needed at the time of the assessment appointment: 1) Washington Department of Licensing Driving Record/Abstract, 2) Police Report of the DUI incident, 3) A urine analysis (UA) sample collection, 4) Criminal Record if available. Clinical Staff will not be able to proceed with the assessment appointment if Driving Record and Police Report are not presented. This will result in rescheduling of the appointment.

Reason for Referral (check all apply) *

Parent/Family/Friend concerns of emotional health and/or substance use behaviors

Service Provider concerns of emotional health and/or substance use behaviors

Self-Referred/Individual concerns about their emotional health and/or substance use behaviors

Legal requirements/Deferred Prosecution

Required

Please provide a brief description of presenting concerns

Is the individual REQUIRED to follow through if treatment is recommended? *

Yes

Other:

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