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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

    Child information

    MM slash DD slash YYYY
    Gender
    Insurance

    Family contact information

    Name(Required)
    MM slash DD slash YYYY
    Address
    Interpreter needed?

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

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

    Developmental and educational support
    Health services
    Basic needs
    State and Federal programs
    Family support