Referral Form Your Name First Name Last Name Your relationship to the person in need of advocacySelectSelfParentCaregiverGuardianSiblingOtherPlease describe Contact Email address Enter Email Confirm Email PhoneAbout the person in need of advocacy:Name of person First Name Last Name GenderSelectFemaleMaleNon-binaryAge County of ResidenceSelectWashington, PAOtherPlease describe Type of advocacy needed/Reasons/Concerns for contacting The Arc of Washington (check all that apply) Applying/Eligibility for services Concerns with current services Difficulty accessing services Employment Early Intervention services (Birth – 3rd birthday) Guardianship Housing Special Education (IEP/504 Plans) Transitioning into adulthood from school Mental Health/Behavioral Health Behavior Supports Other Please describe Brief description of your concerns and/or questions and any pertinent information about the area(s) checked abovePrimary means of communicationSelectEnglish languageBrailleSign LanguageOtherPlease describe DiagnosisSelectAutismBehavioral HealthDevelopmental/ Intellectual DisabilityNot SureOtherPlease describe What services/supports does the person currently receive? Behavioral/Mental Health Community living/residential Community participation supports Day program Employment Early Intervention Educational school district/college Wrap Around Services/Therapeutic Support Staff (TSS) Respite Supports Coordination/Case Management None Not Sure State or County funding sourceSelectSocial Security Disability Insurance (SSDI)Waiver FundingBehavioral Health Managed CarePUNS Waiting ListOtherNoneNot SurePlease describe CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
