Catholic Charities Outpatient Referral

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Referral Date *

Please include Full date: Month Number, Day of the month and four digit date.

YYYY

Person Referring *

Phone #/Ext *

Referring Person information. If your number has an extension start the extension number with "x" like 555-555-5555 x1234

Email address

Enter you email if you would like a email summary of this referral.

Referring to Catholic Charities Location *

The Area of service is for Central Washington. If you are unsure if there are services in your area select Unknown and we will use your address information and have the facility closest make contact. If you select Other and are outside of our service area we will coordinate with other Catholic Charities organization to help with your referral.

Richland

Wenatchee

Yakima

Unknown

Other:

Referral Type *

Self Referral is from any individual that is interested in services for then self (parent/guardian referring their child). External Referrals are from anyone who is not a Catholic Charities Program. Internal referrals are for Catholic Charities programs

Self

External Referral

Internal Catholic Charities Referral

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