Instructions

Please receive verbal consent from the family or caregiver you are referring before completing this referral form.

A Help Me Grow Washington Family Resource Navigator will reach out to the family ASAP. 

In order for us to best meet this family’s needs, please provide as much detail as possible. Questions marked with * are required.

SPECIAL INSTRUCTIONS FOR EMERGENT SITUATIONS: If you are concerned for your client and their family’s safety, please call your county’s crisis line or 911 for immediate support.


Plan of Safe Care Referrals: If you are a birthing hospital social worker, nurse or physician or a DCYF intake staff person trying to make a Plan of Safe Care referral for a birthing parent with a newborn with prenatal substance exposure, please make sure you started with the DCYF SafeCare Portal here. If you have already completed the DCYF SafeCare Portal, please continue on this Help Me Grow referral form.

Geographic Area

Consent

Referral Overview

Please select one or more
View examples of our areas of support

We provide information and referrals in the following service areas

Childcare, preschool, or early learning : free play groups, reduced cost childcare/preschool options.

Child development services : Child development services: developmental screening & assessment, in-home support, early intervention, autism and other special healthcare needs.

Disability supports for children: special healthcare needs, early intervention, screenings, social support, etc.

Employment & financial assistance: employment resources, job training, unemployment benefits, etc.

Food: food bank, WIC, baby food, SNAP, EBT, etc.

Healthcare or health insurance : healthcare, health insurance, dental, immunizations, etc.

Housing & utilities : housing assistance, Coordinated Entry, utility assistance etc.

Items for pregnancy, baby, or family: clothing, diapers, formula, car seats, toys, kitchen supplies, toiletries, etc.

Mental & behavioral health: parent/caregiver depression, anxiety, substance use, etc.

Parenting/caregiving supports: support groups, parenting classes, etc.

Substance Use Disorder: treatment options and resources for individuals affected by substances including cannabis, illegal drugs, and/or prescription medication.

Transportation: free/reduced cost transportation, gas vouchers, transportation to medical appointments, car seat safety, etc.

Other

Referring Provider Information

---
:id: 43090
:trigger_type: visibility
:target_value: {}
:target:
  id: 140804
  type: field
  label: Write in the name of your organization
:conditions:
- field:
    id: 140803
    label: Name of referring organization
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2273
  value_label: Other
  component_type: COS.Input.ReactSelect

---
:id: 43091
:trigger_type: input_required
:target_value: {}
:target:
  id: 140804
  type: field
  label: Write in the name of your organization
:conditions:
- field:
    id: 140803
    label: Name of referring organization
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2273
  value_label: Other
  component_type: COS.Input.ReactSelect

472-659-3

---
:id: 43092
:trigger_type: input_required
:target_value: {}
:target:
  id: 140812
  type: field
  label: Referral ID
:conditions:
- field:
    id: 140811
    label: Request Closed Loop
  operator: equals
  data_type: boolean
  value:
    value: true
  value_label: 'True'
  component_type: COS.Input.Boolean

---
:id: 43093
:trigger_type: visibility
:target_value: {}
:target:
  id: 140812
  type: field
  label: Referral ID
:conditions:
- field:
    id: 140811
    label: Request Closed Loop
  operator: equals
  data_type: boolean
  value:
    value: true
  value_label: 'True'
  component_type: COS.Input.Boolean

Please keep the Referral ID in your records. We will only share a status using the Referral ID.

If you have any questions about your referral, you can email ReferralHelp@withinreachwa.org. We ask that you do not call our Help Me Grow Hotline to ask about the status of your referral. 

You will receive an outcome report from Noreply@communityos.org as soon as the case is closed. Your client can opt out of their information being shared with you.

You may receive an additional email asking about your experience with the closed loop referral. We welcome your feedback to improve our process. 

---
:id: 43125
:trigger_type: visibility
:target_value: {}
:target:
  id: 140917
  type: field
  label: Closed Loop Information
:conditions:
- field:
    id: 140811
    label: Request Closed Loop
  operator: equals
  data_type: boolean
  value:
    value: true
  value_label: 'True'
  component_type: COS.Input.Boolean

Head of Household / Caregiver Information

Please select one or more
Please select one or more
---
:id: 43096
:trigger_type: input_required
:target_value: {}
:target:
  id: 140820
  type: field
  label: Email
:conditions:
- field:
    id: 140819
    label: Does this caregiver consent to be contacted by email?
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2479
  value_label: 'Yes'
  component_type: COS.Input.ReactSelect

---
:id: 43097
:trigger_type: input_required
:target_value: {}
:target:
  id: 140822
  type: field
  label: Text Number
:conditions:
- field:
    id: 140821
    label: Does this caregiver consent to be contacted by text message?
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2479
  value_label: 'Yes'
  component_type: COS.Input.ReactSelect

---
:id: 43098
:trigger_type: visibility
:target_value: {}
:target:
  id: 140825
  type: field
  label: Write in preferred language
:conditions:
- field:
    id: 140824
    label: Caregiver's preferred language
  operator: equals_array
  data_type: integer
  value:
    value:
    - 1840
  value_label: Other
  component_type: COS.Input.ReactSelect

---
:id: 43099
:trigger_type: input_required
:target_value: {}
:target:
  id: 140825
  type: field
  label: Write in preferred language
:conditions:
- field:
    id: 140824
    label: Caregiver's preferred language
  operator: equals_array
  data_type: integer
  value:
    value:
    - 1840
  value_label: Other
  component_type: COS.Input.ReactSelect
Please select one or more
$

Children and other household members

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