Olympic Connect Referral Form

Olympic Connect will pair you with a trusted helper who will help connect you to services like transportation, employment assistance and job training, food assistance, health care, child care, and more. Trusted helpers live and work in your community, bringing their expertise and local knowledge to support you in reaching your goals. Anyone can access Olympic Connect. Connecting to a trusted helper at Olympic Connect is free, though some services you are connected to may have a cost. Your trusted helper can help you plan for and navigate expenses.

To get started, fill out this form or call us at 360-301-8252 to tell us more about your needs and goals. The personal and health information you share is used to pair you with the best trusted helper who will help you prioritize your needs, develop an action plan to meet your goals, and connect you to resources and services. Your trusted helper will follow up with you to ensure you get the support you need - for as long as you need it.

A trusted helper will connect with you within one week of submitting this form.

How did you hear about Olympic Connect?

If you selected Service Provider or Other, please specify:

First name*

Last name*

Date of Birth

Month/Day/Year

Preferred Language

Gender

Please note that your insurance does not effect your eligibility for Olympic Connect.

What is the best way to get in contact with you?*

Phone

Mail

Other

Please enter contact information for the best way to get ahold of you:*

Phone: (xxx) xxx-xxxx
Email: olympic@domain.org
Street Address: 111 Main St, Port Townsend, WA, 98368
Other: please specify

Phone number

Street address

Please include street, city, county, state, and zip code (111 Main St, Port Townsend, Jefferson County, WA, 98368)

City*

Number of adults in household

Number of children in household:

Are you currently working with/receiving support from an organization, Tribe, or person to address the above needs?*

Yes

N/A (Not Applicable)

If yes, please provide information of who you are working with (Name, organization/Tribe, contact information)

Are you currently working with/receiving care from an organization/Tribe or person to address the above needs?*

Yes

N/A (Not Applicable)

If yes, please provide information of who you are working with (Name of person, organization/Tribe, contact information)

To help us match you to a trusted helper, please include any additional information about yourself or the needs you selected on this form:

If you are a service provider referring an individual and would like to be contacted when they are connected to a trusted helper, please provide your information here:

1) Your name
2) Name of your organization/Tribe
3) Email and/or direct phone number