Adult BH Services Referral Form
Please fill out as much information as you can when making a referral, this will help WAPI Community Service Staff to serve the youth. Thank you!
Email address *
WAPI Community Services Referral Form
861 Poplar Pl. S., Seattle, WA 98144  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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Type of Service(s) *
Required
Reason for Referral (check all apply) *
Required
Please provide a brief description of presenting concerns
Your answer
Is the individual REQUIRED to follow through if treatment is recommended? *
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