Name *

First Name

Last Name

What counties does your organization serve? *

Please check all that apply.

Chelan County

Douglas County

Grant County

Okanogan County

Other

If you are not in a leadership role at your organization, please confirm that you have been authorized by leadership to make these commitments on behalf of your organization. *

My organization has staff who live and provide services in the North Central Washington region. *

My organization provides services without discriminating against anyone on the basis of age, sex, sexual orientation, gender, gender identity/expression, marital status, race, creed, color, national origin, religion or beliefs, political affiliation, or disability. *

My organization (and its staff) is willing to make referrals into the North Central Community Care Hub using pre-established screening tools and referral processes. *

My organization is willing to accept referrals from the community-based care coordinators of the North Central Community Care Hub. *

My organization (and its staff) is committed to closing the loop on referrals (i.e. reporting back on the general outcome of received referrals, with the client’s consent). *

My organization (and its staff) will make the time to cooperate with members of the Social Care Network to prevent duplication, support alignment, and use existing resources to their fullest potential. *

My organization (and its staff) will engage in Social Care Network meetings designed to increase information sharing, deepen partnerships, and contribute to network-wide process improvements and assessments. *

My organization will provide logos for use on the North Central Community Care Hub website. *

My organization maintains (or will maintain) updated information about our direct services in the WA211 resource directory (the infrastructure NCCCH is leveraging for regional resource directory efforts). *