Online Referral Form for Mental and Behavioral Health Services

Please use this online form to refer someone for our mental, behavioral, and developmental health services in southwestern PA.

I am a...

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Name(*)

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Email(*)

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Phone(*)

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Person's name(*)

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Address(*)

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City/State/ZIP(*)

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Which services are you primarily interested in?(*)

Community Living Arrangements

Behavioral Support Services

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Please provide details about the person you are referring and their needs(*)

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File #4

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