Referral Form

In need of support? Know someone who is?

Please complete this form to express interest in the Foundational Community Supports (FCS) program, or to refer someone else. You may also email a copy to [email protected], or fax it to 253-330-5080.

We’ll let know potential enrollees if they may qualify for the program and if there’s a provider available in their area to work with them.

We welcome all referrals. If you have questions or concerns, please reach out.

Staff can also be reached at 1-877-222-7982 on weekdays from 8 am - 5 pm PST.

Enrollee Information

* Indicates required field

Requesting consideration for enrollment in: *

Supportive housing Supported employment

Name *

First

Last

Date of Birth *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Self- Referral: *

Yes No

Referring party: Please complete the following if not a self-referral.