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Fishline Therapist Referral
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Name of Individual Being Referred:
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Health Insurance Type
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(This is only for data collection purposes, there is NO CHARGE for therapy)
Choose
Private
Medicaid
Medicare
Dual Medicaid/Medicare
Tricare
Indian Health Services
Uninsured
Unknown
Other
Primary Residence Zip Code of Individual:
*
- If you live outside of the Poulsbo area, but work 32 plus hours per week in the below ZIP Codes you may qualify for mental health services (Must provide documentation at time of service)
- If you are unhoused in any of the below ZIP Codes
you may qualify for mental health services
Approved ZIP Codes:
Bangor-98315,
Keyport- 98345
Poulsbo- 98370
Kingston-98346
Suquamish-98392
Indianola- 98342
Hansville-98340
Port Gamble-98364
Choose
98370
98392
98345
98315
98346
98342
98340
98364
Unhoused in Approved Zip Codes
Working 32+ Hours in Approved Zip Codes
Individuals Phone Number:
Your answer
Individuals Email:
Your answer
Referred From:
*
Select all that apply
Fire CARES Team
Kitsap Police Department
Police Department
DSHS
Fishline
Neighbors/Word of Mouth
Kitsap Recovery Center
Peninsula Community Health Services
Walk In (Direct to AMFM)
Other:
Required
Preferred Service
In Person Services
Telehealth Services
No Preference
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Has initial appointment been scheduled with Therapist?
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