Youth Behavioral Health Outpatient Program Referral Form
Email address *
WAPI Community Services Youth Behavioral Health Outpatient Program Referral Form
Seattle: 861 Poplar Pl. S., Seattle, WA 98144  Federal Way: 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 *
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Service(s) Requesting (Check all apply) *
Required
Reason for Referral (check all apply) *
Required
Please provide a brief description of presenting concern
Your answer
Is the youth REQUIRED to follow through if treatment is recommended? *
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