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: *
City, State, Zip: *
Phone Number: *
Email Address:
Parent/Guardian: *
Relationship to Client: *
Home Phone Number:
Can Contact?
 Yes
 No
Leave Message?
 Yes
 No
Cell Phone Number: *
Can Contact? *
 Yes
 No
Leave Message? *
 Yes
 No
Who has legal custody (medical decision-making)? *
Is there an active court order? *
 Yes
 No
Referral Source/Program Staff Name:
Phone Number:
Email Address:
Reason for Referral: *
Additional Information or Requests:
Services Requested: *
 Drug and Alcohol Treatment
 Outpatient Therapy
 Psychiatric Services
 Trauma-Focused Therapy
Barriers that would affect treatment (i.e. interpreter, transportation, childcare, internet connection):
Is the client currently receiving medication management?
 Yes
 No
Medication(s):
Prescriber:
Are there currently any other service providers involved?
 Yes
 No
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:
 Consent to Treat
 Custody Order
 Release for Caregiver
 Release for Insurance
 Interpreter
Documents: