Instructions

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

If possible, please share one of our flyers or rack cards with your client when you make a referral. Materials can be found here.

A Help Me Grow Washington Resource Navigator will reach out to the family within 48 business hours of receiving the referral. 

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, 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.

If you're looking for support for yourself, click here.

Geographic Area

Permission

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

Examples (if applicable): If client has limited cell phone access, phone number is not client's, secondary phone number, preferred name.

Referring Provider Information

Provider is not limited to medical provider types

▾
  • Astria Sunnyside Hospital
  • Astria Toppenish Community Hospital
  • Atlantic Street Center - ParentChild+ Program
  • Benton-Franklin Health District - Nurse-Family Partnership (NFP) Program
  • Cascade Valley Hospital
  • Catholic Charities of Diocese of Yakima - Parents as Teachers Program
  • Central Kitsap Food Bank
  • Chelan-Douglas Health District - Nurse-Family Partnership (NFP) Program
  • Child Care Action Council - Parents as Teachers Program
  • Child Care Aware
  • ChildStrive - Nurse-Family Partnership (NFP) Program
  • ChildStrive PAT- Parents as Teachers Program
  • Children's Village
  • Childrens Administration
  • Chinese Information and Service Center - ParentChild+ Program
  • Clark County Public Health - Nurse-Family Partnership (NFP) Program
  • Columbia Basin Health Association - Parents as Teachers Program
  • Community Action of Skagit County
  • Community Youth Services - Parents as Teachers Program
  • Confluence Health – Central Washington
  • Coulee Medical Center
  • Cowlitz Tribe - Parents as Teachers Program
  • Crisis Connections
  • DCYF (Department of Children, Youth, and Families)
  • DOH- Early Hearing loss Detection Diagnosis and Intervention (EHDDI) Program
  • DSHS Alderwood Community Service Office
  • DSHS Auburn Community Service Office
  • DSHS Bellingham Community Service Office
  • DSHS Belltown Community Service Office
  • DSHS Capitol Hill Community Service Office
  • DSHS Everett Community Service Office
  • DSHS Federal Way Community Service Office
  • DSHS King Eastside Community Service Office
  • DSHS King North Community Service Office
  • DSHS King South Community Service Office
  • DSHS Mount Vernon Community Service Office
  • DSHS Oak Harbor Community Service Office
  • DSHS Rainier Community Service Office
  • DSHS Renton Community Service Office
  • DSHS Skykomish Community Service Office
  • Denise Louie Education Center - Early Head Start Home-Based Program
  • Eastern Washington University - Early Head Start Home-Based Program
  • Eatonville Family Agency
  • El Centro de la Raza - Parents as Teachers Program
  • EvergreenHealth Kirkland
  • EvergreenHealth Monroe
  • First Step Family Support Center - Parents as Teachers Program
  • Forks Community Hospital
  • Friends of Youth - Parents as Teachers Program
  • Gather Church/Centralia - Parents as Teachers Program
  • Gray's Harbor County - Parents as Teachers
  • Harbor Regional Health
  • Harborview
  • Help Me Grow Skagit Family Resource Center
  • Horn of Africa Services - ParentChild+ Program
  • Hummingbird Indigenous Family Services - Family Spirit Program
  • Institute for Family Development - Parents as Teachers Program
  • InterCultural Children and Family Services - Parents as Teachers Program
  • Island Health
  • Jefferson County Public Health - Nurse-Family Partnership (NFP) Program
  • Jefferson Healthcare
  • Kadlec Regional Medical Center
  • Kittitas Valley Healthcare
  • Lake Chelan Health
  • Legacy Salmon Creek Medical Center
  • Lummi Indian Business Council - Family Spirit Program
  • Lydia Place- Parents as Teachers Program
  • Madigan Army Medical Center
  • Mason Health
  • Mid-Valley Hospital
  • Multi-Service Center
  • Multicare Auburn Medical Center
  • Multicare Capital Medical Center
  • Multicare Deaconess Medical Center
  • Multicare Good Samaritan Hospital
  • Multicare Health System - Steps to Effective Enjoyable Parenting (SEEP) Program
  • Multicare Mary Bridge Children’s Hospital
  • Multicare Tacoma General Hospital
  • Multicare Valley Hospital
  • Naval Hospital Bremerton
  • Neighborcare Health
  • Newport Hospital & Health Services
  • North Valley Hospital
  • Okanogan Child Development Association - Parents as Teachers Program
  • Olympic Community Action
  • Olympic Medical Center
  • Open Arms Perinatal Services - Doula Home Visiting Program
  • PeaceHealth St. Joseph Medical Center
  • Pediatrics NorthWest
  • Providence Pavilion for Women & Children
  • Providence Regional Medical Center Everett
  • Public Health Seattle & King County
  • Public Health Seattle & King County - Nurse-Family Partnership (NFP) Program
  • Save the Children Federation, Inc. - Early Steps to School Success Program
  • Sea Mar
  • Seattle Childrens
  • Skagit County Public Health Department - Nurse-Family Partnership (NFP) Program
  • Skagit Family Health Clinic
  • Skagit Pediatrics
  • Skagit Regional Health
  • Skagit Regional Health - Little Mountain Pediatrics
  • South Kitsap Helpline
  • Spokane Regional Health District - Nurse-Family Partnership (NFP) Program
  • St. James Family Center- Parents as Teachers Program
  • St. Joseph Medical Center
  • St. Michaels Medical Center Family Birth Center
  • Swedish Medical
  • Tacoma-Pierce County Health Department
  • Tacoma-Pierce County Health Department - Nurse-Family Partnership (NFP) Program
  • The Suquamish Indian Tribe - Parents as Teachers Program
  • Thurston County Public Health - Nurse-Family Partnership (NFP) Program
  • Tulalip Tribe - Family Spirit Program
  • United Indians of All Tribes - Parents as Teachers Program
  • University of Washington
  • Valley Medical Center
  • Virginia Franciscan Medical Center
  • West African Community Council - ParentChild+ Program
  • Whatcom County - Nurse-Family Partnership (NFP) Program
  • Whatcom Opportunity Council
  • Whidbey Health
  • WithinReach
  • Yakima Valley Farm Workers Clinic
  • Yakima Valley Farm Workers Clinic - Nurse Family Partnership (NFP) Program
  • Yakima Valley Farm Workers Clinic - Parents as Teachers Program
  • Yakima Valley Memorial Hospital - Nurse-Family Partnership (NFP) Program
  • Other
    • ---
:id: 61945
:trigger_type: visibility
:target_value: {}
:target:
  id: 200020
  type: field
  label: Write in the name of your organization
:conditions:
- field:
    id: 200019
    label: Name of referring organization
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2273
  value_label: Other
  component_type: COS.Input.ReactSelect

    ---
:id: 61946
:trigger_type: input_required
:target_value: {}
:target:
  id: 200020
  type: field
  label: Write in the name of your organization
:conditions:
- field:
    id: 200019
    label: Name of referring organization
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2273
  value_label: Other
  component_type: COS.Input.ReactSelect

    ---
:id: 61947
:trigger_type: hidden
:target_value: {}
:target:
  id: 200025
  type: field
  label: Request Closed Loop
:conditions:
- field:
    id: 200019
    label: Name of referring organization
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2435
  value_label: DCYF (Department of Children, Youth, and Families)
  component_type: COS.Input.ReactSelect

    465-402-71

    ---
:id: 61948
:trigger_type: visibility
:target_value: {}
:target:
  id: 200026
  type: field
  label: Referral ID
:conditions:
- field:
    id: 200025
    label: Request Closed Loop
  operator: equals
  data_type: boolean
  value:
    value: true
  value_label: 'True'
  component_type: COS.Input.Boolean

    ---
:id: 61949
:trigger_type: input_required
:target_value: {}
:target:
  id: 200026
  type: field
  label: Referral ID
:conditions:
- field:
    id: 200025
    label: Request Closed Loop
  operator: equals
  data_type: boolean
  value:
    value: true
  value_label: 'True'
  component_type: COS.Input.Boolean

    ---
:id: 61950
:trigger_type: hidden
:target_value: {}
:target:
  id: 200026
  type: field
  label: Referral ID
:conditions:
- field:
    id: 200019
    label: Name of referring organization
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2435
  value_label: DCYF (Department of Children, Youth, and Families)
  component_type: COS.Input.ReactSelect

    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: 61951
:trigger_type: visibility
:target_value: {}
:target:
  id: 200027
  type: field
  label: Closed Loop Information
:conditions:
- field:
    id: 200025
    label: Request Closed Loop
  operator: equals
  data_type: boolean
  value:
    value: true
  value_label: 'True'
  component_type: COS.Input.Boolean

    Client Contact Information

    Important! If your client is a child, enter information for their adult or caregiver

    ---
:id: 61954
:trigger_type: input_required
:target_value: {}
:target:
  id: 200033
  type: field
  label: Text Number, if different from primary phone
:conditions:
- field:
    id: 200032
    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: 61955
:trigger_type: input_required
:target_value: {}
:target:
  id: 200035
  type: field
  label: Caregiver Email Address
:conditions:
- field:
    id: 200034
    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: 61956
:trigger_type: visibility
:target_value: {}
:target:
  id: 200038
  type: field
  label: Write in preferred language
:conditions:
- field:
    id: 200037
    label: If an interpreter is needed, what language is preferred?
  operator: equals_array
  data_type: integer
  value:
    value:
    - 1840
  value_label: Other
  component_type: COS.Input.ReactSelect

    ---
:id: 61957
:trigger_type: input_required
:target_value: {}
:target:
  id: 200038
  type: field
  label: Write in preferred language
:conditions:
- field:
    id: 200037
    label: If an interpreter is needed, what language is preferred?
  operator: equals_array
  data_type: integer
  value:
    value:
    - 1840
  value_label: Other
  component_type: COS.Input.ReactSelect
    $

    Child Information

    Please select one or more