Referral - Recovery InSight, Inc.

Identifying Information

ALL fields must be completed at time of referral

Name(Required)

First Last

Alternative Name

First Last

Date of Birth(Required)

Age >= 14 Must meet age in order to continue referral

Social Security Number(Required)

Date Referred(Required)

Does the individual have PerformCare?(Required)

Yes

No

Medical Assistance ID#

(10 digits)

County Base Service Unit#

Address(Required)

Street Address Address Line 2 City State ZIP Code

Living Situation(Required)

Alone

With Family

With Parent/Guardian

With Others

Supportive Housing

Unhoused/Experiencing Homelessness

Home Phone

Cell Phone

Other Phone

OK to leave a message?(Required)

Yes

No

REL and SOGI Information

Race(Required)

Ethnicity(Required)

Sexual Orientation(Required)

Gender Identity(Required)

Assigned Gender at Birth(Required)

Pronouns(Required)

Primary Written Language(Required)

Primary Spoken Language(Required)

Can the individual speak and understand English?(Required)

Yes

No

Marital Status

Single

Married

Divorced

Separated

Widowed

Partnered

Psychiatric Information

MUST meet criteria for serious mental illness (SMI), which is defined as: A condition experienced by persons 18 years of age and older who, at any time during the past year, had a diagnosable mental, behavioral, or emotional disorder that met the diagnostic criteria within the current DSM and that has resulted in functional impairment, and which substantially interferes with or limits one or more major life activities. Adults who would have met functional impairment criteria during the referenced year without the benefit of treatment or other support services are considered to have serious mental illness. For youth aged 14 up to age 18, there must be the presence of or a history of a serious emotional disturbance or serious mental illness. Substance use disorders and developmental disorders without the presence of SMI are not included.

In what ways could this individual benefit from Peer Support Services?(Required)

Providers

Case Manager Name

Case Manager Phone

Case Manager Agency

Psychiatrist Name

Psychiatrist Phone

Psychiatrist Agency

Therapist Name

Therapist Phone

Therapist Agency

Medical Information

Significant Physical Health Concerns

Primary Care Physician (PCP) Name(Required)

Primary Care Physician (PCP) Phone

Primary Care Physician (PCP) Medical Group

Date of Last Medical Exam

Primary Care Physician (PCP) Address

Street Address Address Line 2 City State ZIP Code

Does the individual have a substance use history?(Required)

Yes

No

Please describe the substance use history

Current Services and/or Supports

Indicate ALL services the individual regularly utilizes(Required)

Day Program

Alcohol/Drug Treatment Services

Probation/Parole

Alcohol/Narcotics Anonymous

Vocational Program

Educational Program

Psychosocial Rehab (i.e. Clubhouse, Drop-in Center)

Other

No activity

Day Program

Alcohol/Drug Treatment Services

Probation/Parole

Vocational Program

Educational Program

Psychosocial Rehab (i.e. Clubhouse, Drop-in Center)

Other

The Peer Support Recommendation Form is needed to complete the referral process. It must be signed by a Practitioner of the Healing Arts: Physician (MD or DO), Licensed Psychologist (PhD or PsyD), Certified Registered Nurse Practitioner (CRNP), Physician’s Assistant (PA or PA-C), Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), or Licensed Marriage and Family Therapist (LMFT)

These forms may be mailed, faxed, or attached below.

Download the Peer Support Recommendation Form

Attach Peer Support Recommendation Form

Max. file size: 128 MB.

Referral Source Information

Name of Person Completing Referral Form(Required)

Phone Number(Required)

Agency

Relationship to individual being referred(Required)

Is referred individual aware of referral?(Required)

Yes

No

Signature of Referred Individual

Signature of Parent/Guardian (if referred individual is under age 18):

Individual Prefers(Required)

Male Certified Peer Specialist

Female Certified Peer Specialist

Doesn’t Matter

Completion of this form acknowledges that individual is aware of all Peer Support providers Lancaster and Lebanon Counties

Recovery InSight, Inc.
(717) 517-8552

WellSpan Philhaven
(717) 221-9610

Peerstar LLC
(888) 733-7781

Make a Referral