Staff Referral Form
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Information
Welcome! Thank you for considering CenClear for your mental health or drug and alcohol treatment needs. This form will be used to refer you, or the person you are referring, for needed services. If you have any questions or need assistance completing this form please call us at 1-877-341-5845 ext. 2391.
No information about you or the person you are referring will be released without written consent. All of our services are confidential.
CenClear does not discriminate on any basis including a person's age, sex, color, race, disability, religious creed, lifestyle or source of payment.
1.
Date of Referral
*
mm/dd/yyyy
2.
Name of Referred Individual:
*
3.
Medical Assistance Number if Applicable:
*
If you do not have Medical Assistance please type "N/A".
4.
Please Provide Your Insurance Information.
If you do not have insurance please type "None" in the Insurance name box.
Insurance Company Name
Policy Holder's Name
Policy Number
Group Number
Insurance Information
5.
Please complete the following information:
*
Age:
Identified Gender:
Date of Birth:
Social Security Number
6.
Please enter the demographic information:
Address:
County:
Phone(Home):
Phone(Work):
Phone(Cell):
Legal Guardian Name (if applicable):
7.
Referral Source:
*
If you are referring yourself please type "self".
Referral Source(Name/Agency):
8.
Please check the CenClear office location is most convenient for you.
*
Brookville, 222 Allegheny Boulevard, Brookville
Clarion, 627 Wood Street, Clarion
Clearfield, 60 Industrial Park Road, Clearfield
Coalport, 122 53 Boulevard, Coalport
DuBois, 2910 Oklahoma Salem Road, DuBois
Huntingdon, 620 Washington Street, Huntingdon
Philipsburg, 1633 Philipsburg Bigler Highway, Philipsburg
Punxsutawney, 117 Elk Run Ave, Punxsutawney
Roaring Spring, 601 Wilson Ave., Roaring Spring
Saint Mary, 427 N. St. Marys St., St. Marys
State College, 3638 N. Atherton St., Port Matilda
Yeagertown, 13193 Ferguson Valley Road, Yeagertown
9.
Have you been discharged from a hospital?
*
Have you been discharged from a hospital?
*
Yes
No
10.
If you have been discharged from a hospital, what is the name of the hospital?