Family Life Services

OPT-IN

877-342-5667

Locations:

Mechanicsburg

960 Century Drive
Mechanicsburg, PA 17055

Phone: (717) 795-0330
Toll-Free: 1-866-700-6868

Lewisburg

1800 West Market Street
Lewisburg, PA 17837

Phone: (570) 524-9477
Toll-Free: 1-800-395-8327

Williamsport

435 West Fourth Street
Williamsport, PA 17701

Phone: (570) 322-7873
Toll-Free: 1-866-244-5760

Montoursville

241 Broad Street
Montoursville, PA 17754

Phone: (570) 433-7060
Toll-Free: 1-866-244-5760

New Bloomfield

25 East McClure Street
New Bloomfield, PA 17068

Phone: (717) 795-0330
Toll-Free: 1-866-700-6868

Diakon does not discriminate in admissions, the provision of services, or referrals of clients on the basis of race, color, creed, religion, sex,
national origin, sexual orientation, age, marital status, veteran status, disability or any other classes protected by law.

Name:	Agency:
Office Phone:	Cell:
Fax:	Email:

First Name:	Last Name:
Age:	Date of Birth:
Address:
Primary Phone:	Other Phone:

Mother:
Address (if different):
Primary Phone:	Other Phone:
Father:
Address (if different):
Primary Phone:	Other Phone:
Emergency Contact (other than Parents):	Phone:
Relationship:	Address:

Regular Education:	Special Education:	Learning Support:	Alt. Education:
Contact Person:	Contact Phone:

BC/BS:	HMO:	Medical Assistance Plan Name:
MA #(10digit State ID):

Diakon Family-Based PSB Referral Form

Referral Source

Client Information

Parent/Guardian and Emergency Contacts

School/Education Information

Type of Insurance Information

Medical Information

Additional Agencies/Providers (i.e. CYS, JPO, Case Mgmt, Mental Health, Psychiatrist)

Reason For Referral

Current Medication and Dosages:
Medication Prescribed By:	Phone:	Client Allergies:

Agency/Provider:	Contact Name:
Address:
Phone:	Fax:
Agency/Provider:	Contact Name:
Address:
Phone:	Fax:
Agency/Provider:	Contact Name:
Address:
Phone:	Fax: