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Pacific Treatment Alternatives

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Referral Form

Referral Form to the
Parent Child Assistance Program
(formerly Safe Babies Safe Moms)

Pacific Treatment Alternatives
1721 Hewitt Ave, STE 200
Everett WA 98201-3582
425-259-7142 ext 200
Fax: 425-317-0105

Eligibility Requirements
Please check all that apply. The client must be:*
- Pregnant OR
- Up to 12 months postpartum
- Or up to 24 months postpartum if there is space available
AND*
- Able to self-report to PCAP heavy use of alcohol or other drugs during her pregnancy
- ineffectively connected to community services
- NOT be enrolled in another P-CAP program
In addition, at least one of the following criteria must be met:
- 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
MM slash DD slash YYYY
Age
Medicaid Coupon Code
Address
Street Address City State ZIP Code
Primary Phone Number
Alternate/Message Phone Numbers
Please answer the next question only if Mom does not have a Medicaid Coupon:
Is a child in the family Medicaid eligible? Note: The child does not have to be in the mother’s custody?
- Yes
- No
Child Name
Date of Birth
MM slash DD slash YYYY
For more information about the Parent Child Assistance Program please call Pacific Treatment Alternatives at 425-259-7142 ext 200.

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Over 50 Years of Service Founded in 1969

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