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Children & Youth with Special Health Care Needs Referral

Tacoma-Pierce County Health Department is committed to protecting the confidentiality of your medical information, and the law requires us to do so. Read the complete Notice of Privacy Practices.

Referral information

Name of person making referral(Required)

First Last

Agency name (if applicable)

Email(Required)

Phone(Required)

Child information

First name(Required)

Last name(Required)

Date of birth

Gender

Female

Male

Race

Ethnicity

Insurance

Medicaid

Tricare

Private

No insurance

Medicaid Provider One number (if available)

Primary care provider and location

Primary guardian information

Name(Required)

First Last

Date of birth

Are you the parent or legal guardian of the child?(Required)

Yes

No

Unknown

Relationship to child(Required)

Address

Street address City State ZIP code

Primary phone(Required)

Alternate phone

Email

Interpreter needed?

Yes

No

Interpretation language

Please list any diagnoses, medical, or developmental concerns for this child and any additional relevant information.

Describe condition or diagnosis

Additional comments or needs

Please identify services or supports that may benefit this child and/or family.

Developmental and educational support

Early Support for Infants & Toddlers (ESIT) (previously Birth to Three)

Developmental preschool

Individualized Education Program (IEP/504 Student Plan support)

Health services

Primary or specialty medical care

Therapies (OT, PT, speech)

Nutrition or feeding

Applied behavioral analysis (ABA)

Behavioral health

Durable medical equipment or supplies

Basic needs

Food

Transportation

Housing

Utilities

State and Federal programs

Supplemental Security Income (SSA)

Developmental Disabilities Administration (DDA)

Health insurance support

Family support

Respite care

Support and advocacy groups

Other referral needs

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