Request Services Form

Serving children in East Jefferson County

We are located in Port Townsend, Washington and serve East Jefferson County on the Olympic Peninsula.

Child's name (first and last)

Child's age

Child's gender

Guardian/Parent Name (first and last)

Relationship to child

Referred by (optional)

Best contact phone

Okay to leave message?

Guardian/Parent email

Legal guardian?

If no, name of guardian

Have any other family members been seen at Jumping Mouse before?

If yes, who was seen and when? (optional)

Notes (reason for wanting service)