Fishline Therapist Referral
Name of Individual Being Referred: *
Date of Birth *
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Health Insurance Type *
(This is only for data collection purposes, there is NO CHARGE for therapy)
Individuals Phone Number:
Individuals Email:
Referred From: *
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Preferred Service
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Has initial appointment been scheduled with Therapist? *
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
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