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

  • Date Format: MM slash DD slash YYYY

  • Please answer the next question only if Mom does not have a Medicaid Coupon:

  • Date Format: 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.