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Please use the form below to make a referral to the Center for Counseling and Wellness at Family Services of NW PA. To learn more about the services we offer, click here.

Instructions: Referral form should be completed by referring worker/organization with input from the family. Please complete all fields. If unsure or not applicable, indicate on the form. If you have questions, please email cdesk@fsnwpa.org. or call 814.866.4500.

Client Name:
Social Security Number:
Date of Referral:
Date of Birth:
Gender:
Address:
Phone Number:
Email Address:
Parent/Guardian:
Relationship to Client:
Home Phone Number:
Can Contact?
Leave Message?
Cell Phone Number:
Can Contact?
Leave Message?
Who has legal custody (medical decision-making)?
Is there an active court order?
Referral Source/Program Staff Name:
Phone Number:
Email Address:
Reason for Referral:
Additional Information or Requests:
Services Requested:
Barriers that would affect treatment (i.e. interpreter, transportation, childcare, internet connection):
Is the client currently receiving medication management?
Medication(s):
Prescriber:
Are there currently any other service providers involved?
Provider name and contact information:
Current Diagnosis (if available):
Diagnosed by:
Insurance Provider:

For internal referrals only: Please complete the below information and attach the following documents
OCY Caseworker:
Phone Number:
Email Address:

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Who We Are
About Us
Senior Leadership
Program Managers
Board of Directors
Locations
Careers
Internships
History
Contact Us
What We Do
Programs and Services
Counseling Services
Permanency Services
Community Support Services
Success Stories
Annual Reports
Get Involved
Ways to Give
Ways to Help
Become a Mentor
Become a Foster Parent
Become an Adoptive Parent
Donate
News
Site Search
Donate