Request for Liaison Services Form Today's Date(Required) MM slash DD slash YYYY What service(s) are you requesting? Mental Health Referral SUD Services Referral Supportive Housing Transportation Harm Reduction Name(Required) First Last Date of Birth MM slash DD slash YYYY Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I do not have an address/I am unhoused Phone Number Where You Can Be ReachedI do not have a phone number (You can reach WSTC at (360) 876-9430) Email Do You Have: Medicaid Private Insurance Private Pay No Funding or Medicaid Are you interested in WorkSource? yes no Help us understand what you are seeking. Check all that apply: I struggle getting from Point A to Point B due to transportation issues such as lack of safe vehicle, a valid driver’s license, lack of gasoline, etc. I have work or career goals that my transportation barriers keep me from achieving. I am at risk of becoming homeless. I am currently in a toxic living environment. I need help with drug addiction. I would like help learning how to set mental health boundaries. I am – or someone who knows me is – concerned about my mental health. I am dealing with traumatic events. I would like help with relationship issues. I am at risk for domestic violence. I need harm reduction resources. In your own words, tell us the reason for your request:What is your desired outcome?What appointment days and times work best for you? Morning (8:00 am to 12:00 pm) Afternoon (12:00 pm to 5 pm) Monday Tuesday Wednesday Thursday Friday If you are only available before 8 am or after 5 pm, will phone or video calls serve your need? (If this does not apply, write NA.) Download QR
