Individual Choice of Providers

Individual Choice of Providers

ARC Manor
Name of Client*

First NameLast Name
CHECK DESIRED LOCATION OF TREATMENT: (Co-occurring enhanced facilities are denoted with (*)
Outpatient Providers*

ARC Manor Leechburg OPARC Manor OP/IOP/PartialCenClear Brookville OP/IOPCenClear Clarion OP/IOP/PartialCenClear Punxsutawney OP/IOPThe Open Door OP/IOP/PartialWesley Family Services OP/IOP/PartialWhite Deer Run/Cove Forge Partial-Overnight
Withdrawal Management Non-Hospital Providers Adult

Alpine SpringsBradford Recovery CenterClear Day Treatment of WestmorelandCove Forge Behavioral Health System*Firetree, Conewago IndianaFiretree, Conewago PottsvilleGateway AliquippaGateway Mt. PleasantGaudenzia ErieGreenbriar Treatment CenterPyramid Healthcare-DuncansvillePyramid HealthCare-HillsidePyramid HealthCare-WilkinsburgRoxburySpirit LifeTwin LakesWhite Deer Run AllenwoodWhite Deer Run Lancaster
Residential Adult

Alcohol and Drug Abuse Services- Maple Manor *Alpine SpringsARC ManorBradford Recovery CenterClear Day Treatment of WestmorelandCove Forge Behavioral Health System *Firetree, Conewago Indiana*Firetree, Conewago PlaceFiretree, Conewago PottsvilleFiretree, Conewago SnyderGaiser Addiction CenterGateway AliquippaGateway ErieGateway Mt. PleasantGaudenzia Erie *Gaudenzia Erie- House of HealingGlenbeighGreenbriar Treatment Center *Oil Region RecoveryPyramid HealthCare Duncansville *Pyramid HealthCare-BellevillePyramid HealthCare-Hillside *Pyramid HealthCare-Wilkinsburg *Renewal TreatmentRoxbury*Samara House of CYWASojourner HouseSpirit LifeTwin LakesWhite Deer Run Allenwood *White Deer Run LancasterWhite Deer Run New Perspectives *
Withdrawal Management/Residential Adolescent

Gateway AliquippaPyramid Duncansville WMPyramid Hillside WMPyramid Ridgeview No WM
Halfway House Adult Male

Another WayClem-Mar House EdwardsvilleFiretree, Conewago New Way of LifeGateway Moffett HouseGateway Tom Rutter HouseGaudenzia Erie Daniel SnowGreenbriar Lighthouse for Men *HH of Lehigh ValleyPyramid HealthCare Gratitude HousePyramid HealthCare Pine Ridge
Halfway House Adult Female

Abstinent Living at Turning Point WashingtonClem-Mar House DallasGateway Cece's PlaceGaudenzia Erie Community HouseGreenbriar Lighthouse for Women *HH of Lehigh ValleyHighland HousePyramid HealthCare-Tradition House
Enhanced Withdrawal Management/Hospital WM/Rehab Adult

ACMHGlenbeighMeadville Medical Center- Stepping Stones
Medication Assisted Treatment

ARC Manor BuprenorphineCenClear Bupenorphine/VivitrolIRMC Physicians Group-BupenorphineMedMark-MethadonePositive Recovery Solutions- VivitrolThe Open Door BupenorphineWesley Family Services Buprenorphine/Vivitrol
I accept a copy of this release:*

YesNo
Client Signature*
Date Signed by Client*
Witness Signature*
Witness Name*

First NameLast Name
Date Signed by Witness
Should be Empty: