Web Site Referral Date: Client or parent/guardian has given consent to share this information for enrollment into the care coordination program. Yes, client has given consent. Referral Source Agency making the referral: Referring person: Other referral information: Referral contact #: Client Information Client Type: * Adult Pediatric Pregnant Insurance Status * Medicare & Medicaid (Dual Eligible) Medicare Medicaid Uninsured Private Other COVID-19 COVID-19 Referral Referral is not due to COVID. Date tested for COVID-19 (if applicable) WDRS Event ID or Case Investigator/Contact Tracer (COVID only) Medicaid ID: First Name: * Middle Name: Last Name: * Previous Name: Date of Birth: * Gender: * Ethnicity Hispanic or Latino Not Hispanic or Latino Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White/Caucasian Address 1: * Address 2: City: * State: * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Email Address: County: * Island San Juan Skagit Snohomish Whatcom Zip Code: * Phone Number: * Alternate Phone Number: Needs help with connection to (select all that apply): COVID Related Services Housing No Insurance Mental Health/Behavioral Health Substance Use Tobacco Use Transportation Childcare Less than 18 years old Safety Concerns Pregnancy Reproductive/Sexual Health Primary Care needed Specialty care needed Medication Assistance Challenges with medical appointments Low income Food Other Provider Provider: Practice: Phone: Type of Provider Primary Care Provider Behavioral or Mental Health Provider Other Other Provider(s): Referral Notes (optional):