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Referral Form
Referral
(Required)
Therapy
Meds
IBHS
ABCs
School Based
Other
Referred By:
(Required)
Phone
(Required)
Email
(Required)
Name of Client
(Required)
Gender
(Required)
Gender
Male
Female
Non-binary
Agender
My gender is not listed
Prefer not to answer
Date
(Required)
MM slash DD slash YYYY
Client Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Client Phone
(Required)
Client Cellphone
(Required)
Client Marital Status
(Required)
Social Security Number
(Required)
MA ID Number
(Required)
School
School
BERMUDIAN SPRINGS SCHOOL DISTRICT
CARLISLE AREA SCHOOL DISTRICT
DALLASTOWN AREA SCHOOL DISTRICT
DOVER AREA SCHOOL DISTRICT
NORTHERN YORK COUTNY SCHOOL DISTRICT
NORTHEASTERN SCHOOL DISTRICT
SOUTHERN YORK COUNTY SCHOOL DISTRICT
SOUTHWESTERN SCHOOL DISTRICT
SPRING GROVE AREA SCHOOL DISTRICT
WEST YORK AREA SCHOOL DISTRICT
YORK COUNTY SCHOOL OF TECHNOLOGY
YORK COUNTY YOUTH DEVELOPMENT CENTER
YORK SUBURBAN SCHOOL DISTRICT
Name of Parents / Guardians
(Required)
Who Has Medical Rights?
(Required)
*Please Include copies of custody agreements and/or court documents verifying legal, medical and educational rights at the bottom of this form.
Untitled
(Required)
Secondary Insurance
ID Number (Primary Insurance)
(Required)
ID Number (Secondary Insurance)
Name of Insured (Primary Insurance)
(Required)
Name of Insured (Secondary Insurance)
DOB of Insured (Primary Insurance)
(Required)
DOB of Insured (Secondary Insurance)
Insurance Phone (Primary Insurance)
(Required)
Insurance Phone (Secondary Insurance)
Areas of Concern:
(Required)
Is the Client in Treatment Now?
(Required)
Is the Client in Treatment Now?
Yes
No
Where?
(Required)
Last Phychiatric Evaluation
(Required)
MM slash DD slash YYYY
Current Diagnosis (If Any)
(Required)
Days Available
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Files
(Required)
Drop files here or
Select files
Accepted file types: pdf, doc, txt, png, jpg, Max. file size: 2 MB.
*Please upload any relevant documentation like custody agreements and/or court documents verifying legal, medical and educational rights.
Our locations
We proudly serve families across Central Pennsylvania with locations in:
York County
2555 Cape Horn Road
Red Lion, PA 17356
717.600.0900
717.600.0910 Fax
admin@pcbh.org
Lancaster County
20B East Roseville Road
Lancaster PA 17601
717.560.2372
717.560.2027 Fax
admin@pcbh.org
Adams County
304B York Street
Gettysburg PA 17325
717.420.2209
717.420.2715 Fax
admin@pcbh.org
Cumberland County
1000 North Front Street, 4th Floor
Wormleysburg PA 17043
717.550.1701
717.550.1702 Fax
admin@pcbh.org
Please call ahead or use the request form to connect with your nearest location.
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