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.
Adult Evaluation (18 yrs and Over)
Minor Evaluation (Under 18 yrs)
Adult Counseling (18 yrs and Over) (Use for Family/Marital Counseling)
Minor Counseling (Under 18 yrs)