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 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 trying to make a Plan of Safe Care referral, please start here.

Geographic Area

Consent

Referral Overview

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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.

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

Other

Referring Provider Information

---
:id: 32854
:trigger_type: visibility
:target_value: {}
:target:
  id: 104922
  type: field
  label: Write in the name of your organization
:conditions:
- field:
    id: 104921
    label: Name of referring organization
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2273
  value_label: Other
  component_type: COS.Input.ReactSelect

---
:id: 32855
:trigger_type: input_required
:target_value: {}
:target:
  id: 104922
  type: field
  label: Write in the name of your organization
:conditions:
- field:
    id: 104921
    label: Name of referring organization
  operator: contains_array
  data_type: integer
  value:
    value:
    - 2273
  value_label: Other
  component_type: COS.Input.ReactSelect

---
:id: 32856
:trigger_type: input_required
:target_value: {}
:target:
  id: 104930
  type: field
  label: Closed Loop Request Unique ID
:conditions:
- field:
    id: 104929
    label: Closed Loop Request
  operator: equals
  data_type: boolean
  value:
    value: true
  value_label: 'True'
  component_type: COS.Input.Boolean

Head of Household / Caregiver Information

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Please select one or more
---
:id: 32859
:trigger_type: input_required
:target_value: {}
:target:
  id: 104938
  type: field
  label: Email
:conditions:
- field:
    id: 104937
    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: 32860
:trigger_type: input_required
:target_value: {}
:target:
  id: 104940
  type: field
  label: Text Number
:conditions:
- field:
    id: 104939
    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: 32866
:trigger_type: visibility
:target_value: {}
:target:
  id: 104972
  type: field
  label: Write in preferred language
:conditions:
- field:
    id: 104942
    label: Caregiver's preferred language
  operator: equals_array
  data_type: integer
  value:
    value:
    - 1840
  value_label: Other
  component_type: COS.Input.ReactSelect

---
:id: 32867
:trigger_type: input_required
:target_value: {}
:target:
  id: 104972
  type: field
  label: Write in preferred language
:conditions:
- field:
    id: 104942
    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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