LifeSet Snohomish Referral Form
This program will serve youth and young adults currently being served in or exiting the DCYF Child Welfare or Juvenile Justice system who are between the ages of 17 to 22 years old, currently living in Snohomish County and meet at least one of the following criteria:

(1) Experiencing homelessness or has a history of housing instability;
(2) Expectant or parenting;
(3) Involved with Commercial Sexual Exploitation of Children (CSEC);
(4) Struggled to achieve independent living goals and/or historically not engaged with services
(5) Experiencing mental health challenges and relationship struggles; or
(6) Dually involved in child welfare and juvenile justice systems.
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Date *
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Who is completing this referral?  *
If you selected "Community Partner" as the referral source, please provide your contact information. 

Name, Email, Phone, Relationship to the young person
 *
Full Legal Name of Young Person being referred: *
Date of Birth *
MM
/
DD
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YYYY
Age at time of Referral *
Gender *
Ethnicity/Race *
Required
Primary Language *
Young Person's Cell Number *
Young Person's Email Address *
Young Person's Address *
Young Person's Strengths and Positive Attributes:  *
Identified Needs *
Required
Additional information useful for us to know about you/the young person: *
Questions or concerns? 
If you have further questions or concerns, please reach out to the LifeSet Snohomish Supervisor, Kristina Williams. Email: kwilliams@youthnetnw.net   Cell: 360-814-9441
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