Referral Form

Eligibility Requirements

Please check all that apply. The client must be:*

AND*

Have a history of multiple system involvement with PCAP being the only service available to meet her complex needs.
NOT be enrolled in another P-CAP program.

In addition, at least one of the following criteria must be met:

The client used alcohol or other drugs at any time during her pregnancy.
The client used alcohol or other drugs within the past six months.
The client has had a Chemical Dependency (CD) assessment within the past 6 months which recommended CD treatment or which diagnosed the client as being dependent on alcohol or other drugs. (Please send copy to PTA.)
A professionally licensed PCAP staff has written a justification explaining why the woman is in serious risk of substance abuse and why she needs PCAP services. (Please send copy to PTA.)

Name

First Last

Date of Birth

Age

Medicaid Coupon Code

Address

Street Address City State ZIP Code

Primary Phone Number

Alternate/Message Phone Numbers

Is a child in the family Medicaid eligible? Note: The child does not have to be in the mother’s custody?

Child Name

Date of Birth

For more information about the Parent Child Assistance Program please call Pacific Treatment Alternatives at 425-259-7142 ext 200.