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Self Referral Form

Date
MM slash DD slash YYYY
Name
First Last
Email
Age
- Male
- Female
DOB
MM slash DD slash YYYY
SS#
Possible/Actual Diagnosis Of
- Autism Spectrum Disorder
- Intellectual Disabililty
Medical Assistance
- Yes
- No
If Yes, MA ID#
Community Health Choices - Support Eligible:
- Yes
- No
- Unknown
Community Health Choices - Waiver Eligible:
- Yes
- No
- Unknown
County of Residence
Residential Setting
- Lives Alone
- Lives with family
- Group Home
- Other
Current Address
Street Address Address Line 2 City State ZIP Code
Current Phone Number
Primary Contact Person if not self:
First Last
Primary Contact Phone Number
Relationship to Referral Name
Reason for Referral

Contact Us

766 East Pittsburgh Street, Greensburg, PA 15601
Office (724) 836-6215
Compliance Hotline (724) 510-7813
Fax (724) 217-8086

Operating Hours

Monday -Friday 8:30 A.M – 4:30 PM
Saturday & Sunday CLOSED

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