Peer Support Referral
Referring Person Information
County
*
Please Select
Adams County
Allegheny County
Armstrong County
Beaver County
Bedford County
Berks County
Blair County
Bradford County
Bucks County
Butler County
Cambria County
Cameron County
Carbon County
Centre County
Chester County
Clarion County
Clearfield County
Clinton County
Columbia County
Crawford County
Cumberland County
Dauphin County
Delaware County
Elk County
Erie County
Fayette County
Forest County
Franklin County
Fulton County
Greene County
Huntingdon County
Indiana County
Jefferson County
Juniata County
Lackawanna County
Lancaster County
Lawrence County
Lebanon County
Lehigh County
Luzerne County
Lycoming County
McKean County
Mercer County
Mifflin County
Monroe County
Montgomery County
Montour County
Northampton County
Northumberland County
Perry County
Philadelphia County
Pike County
Potter County
Schuylkill County
Snyder County
Somerset County
Sullivan County
Susquehanna County
Tioga County
Union County
Venango County
Warren County
Washington County
Wayne County
Westmoreland County
Wyoming County
York County
Date
*
-
Month
-
Day
Year
Date
Referring Persons Name
*
First Name
Last Name
Relationship to Peer
*
Please Select
Spouse
Significant Other
Parent
Friend
Peer
Other
Other Relationship to Peer
Title/Relation
Referring Persons Phone Number
*
Please enter a valid phone number.
Referring Persons Email
*
example@example.com
Referring Agency/Physician
*
Language Preference
*
Please Select
English
Spanish
Interpreter Needed?
*
Yes
No
How did you hear about us?
Peers Information
Peer Legal Name (with middle initial)
*
First Name
Middle Name
Last Name
Peer Preferred Name
*
First Name
Last Name
Peers Phone Number
*
Please enter a valid phone number.
Peers Email
*
example@example.com
Is it okay to text/email?
*
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Peers Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
State
Medical Information
Physician Name
*
Prefix
First Name
Last Name
Physicians Phone Number
*
Please enter a valid phone number.
Insurance Information
*
Diagnosis (If known)
*
Historical Information
Reason for referral?
*
Please Select
Crisis Support
Community Roles/Support
Individual Advocacy
Self Help
Self Improvement
Wellness Recovery
Social Networking
Reason for Referral
Treatment History (If Known)
*
Does the Peer has a history of Incarceration?
*
Yes
No
Facility
Release Date
Reason for Incarceration
Comments
Any additional comments?
Submit
Should be Empty: