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:
Other Services (Workplace Request, Surgical Procedure Request, etc.):
Adult Counseling (18 yrs and Over) (Use for Family/Marital Counseling)
Minor Counseling (Under 18 yrs)