G2L Connection Desk Referral Form

The G2L Connection Desk, located on the first floor, will match community members with a volunteer
who can connect you to the resources that you need. We have bilingual volunteers who speak the following
languages: Mandarin, Nepali, Hindi, Somali, Spanish, Tigrinya, Teo-Chou, Serbian and Vietnamese.
Please fill out your referral form and drop it off at the G2L Connection Desk located on the first floor. If
you have any questions please call us at 206.816.3243 or 206.816.3266
Resources that I would like to be connected to:
Finding an ESL Class
Yes No

Finding an employment
training program
Yes No

Applying/Finding a food
assistance program
Yes No

Finding a computer class

Yes No

Baby and children items such as diapers, carseats, childcare, others

Yes No

Finding programs for my kids

Yes No

Information about
ORCA Lift Program
Yes No

Sign me up for nutrition and/or

fitness class
Yes No

Assistance and information

for my health insurance
Yes No
Clothing assistance for
myself and/or my children
Yes No
Information about utilities
assistance
Yes No

Finding me legal assistance

(tenant rights, immigration)
Yes No
Information
on housing and
emergency rent assistance
Yes No

Sign me up for the following Global to Local mobile health program:

(This Program is only in English)
Diabetes Management
Smoking Cessation
Weight Management

Additional Comments and/or Resources I need:

G2L Connection Volunteer Section (Volunteer Name: ________________________)

Client is being connected to the following resources:
ESL Class Childcare Summer Program Employment Training Program Computer Class
Help with job application Utilities Assistance Food Assistance Program Summer Lunch Program
Housing Assistance Transportation Service Legal Assistance Parenting Class Clothing Assistance and
Items for myself and/or children Other:______________________________
Volunteer Notes: The Client is a HealthPoint patient Yes No

Contact Information - Referred by: _________________ Date: ______________

Name:

Best way to contact: Phone or Email (Please Circle)

Preferred Language:

Phone Number:

DOB:

Email:

Zip Code :

Is it ok to contact you via phone? Yes

No

Area you are currently living in: Auburn Burien Des Moines Kent Renton SeaTac
Seattle

 Tukwila Other:______________________