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Make a Referral

Anyone, including the individual, can make a referral to Peer Support Services.

Step 1 of 6

16%

Identifying Information

ALL fields must be completed at time of referral
Peer Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Age >= 14 Must meet age in order to continue referral
Does the individual have PerformCare?(Required)
(10 digits)
Gender(Required)

Marital Status
Race/Ethnicity(Required)
Can the individual speak and understand English?(Required)
Living Status
Home Address(Required)
Use the home address above as the mailing address
Mailing Address(Required)
Phone 1 Type(Required)
Phone 2 Type
Phone 3 Type
OK to leave a message?
Reason for Referral(Required)

Psychiatric Information

Eligibility is targeted to individuals diagnosed with a Serious Mental Illness (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 a 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.

Individuals eligible for services would benefit from support in at least one of the following domains: Educational (e.g., obtaining a high school or college degree); Social (e.g., developing a social support system); Vocational (e.g., obtaining part-time or full-time employment; and Self-Maintenance (e.g., managing symptoms, understanding his or her illness, managing money, living more independently).

Providers

Medical Information

Primary Care Physician (PCP) Address
Does the individual have a substance use history?(Required)

Current Services and/or Supports

Indicate ALL services the individual regularly utilizes(Required)
The following documents are needed to complete the referral process (to avoid delay, please provide all requested information)(Required)

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

CLICK HERE to Download "Peer Support Recommendation Form"

Max. file size: 128 MB.

Referral Source Information

Is referred individual aware of referral?(Required)
Reset signature Signature locked. Reset to sign again
Individual Prefers(Required)
Recovery InSight, Inc. (717) 517-8552 WellSpan Philhaven (717) 221-9610 Merakey (888) 647-0020 Keystone Human Services (717) 482-8500 Peerstar LLC (888) 733-7781(Required)
Recovery InSight, Inc.
(717) 517-8552

WellSpan Philhaven
(717) 221-9610

Merakey
(888) 647-0020

Keystone Human Services
(717) 482-8500

Peerstar LLC
(888) 733-7781

About Recovery InSight, Inc.

It is our mission to be involved in the process of making positive changes in people’s lives by providing support with the highest integrity and compassion to individuals working towards recovery, by individuals in recovery, with similar experiences.

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