Forms

If you are interested in being seen at Providence Behavioral Health, please fill out the appropriate form below.  If you have any questions, please call our office at 717-397-1400.

If you are a doctor’s office or skilled nursing facility referring a patient, please fax your referral form to our office at 717-509-4066, Attn: Client Services.  Be sure to include the referring provider information (name, contact info, etc.) and the reason for the referral.

Neuropsychological, Psychological or Education Evaluations (Testing):

Adult Evaluation (18 yrs and Over)

Minor Evaluation (Under 18 yrs)

General Counseling Forms:

 

Adult Counseling (18 yrs and Over) (Use for Family/Marital Counseling)

Minor Counseling (Under 18 yrs)

Other Services (Workplace Request, Surgical Procedure Request, etc.):

General Registration Information