Youth Behavioral Health Outpatient Program Referral Form

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WAPI Community Services Youth Behavioral Health Outpatient Program 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

Service(s) Requesting (Check all apply) *

Substance Use Disorder (SUD) Screening, Assessment, Support, and Treatment Services

Behavioral Health Screening and Support Services

SBIRT

Other:

Required

Reason for Referral (check all apply) *

School staff concerns of emotional health and/or substance use behaviors

Parental concerns of emotional health and/or substance use behaviors

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

Legal Requirements (ie. DUI, probation, etc.)

Self-Referred

Other:

Required

Please provide a brief description of presenting concern

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

Yes

Other:

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