Referral Forms and Releases

 

Single Point of Accountability (SPA) Forms

Glade Run Services
Blended Case Management (BCM) Referral Form
Glade Run BCM Information
Glade Run Release of Mental Health Information

Staunton Clinic
Allegheny County Blended Service Coordination – Adult Referral Form
Allegheny County Blended Service Coordination – Child Referral Form
Beaver County Blended Service Coordination – Adult Referral Form
Beaver County Blended Service Coordination – Child Referral Form
HVHS (Staunton Clinic) HIPAA Authorization

BCBH Direct Services Unit (DSU)

Blended Case Management (BCM) Referral Form
DSU HIPAA Authorization

Cornerstone Recovery Services (CRS)
CRS Referral Packet including Blended Case Management
CRS HIPAA Authorization

Merakey (formerly NHS)
Adolescent BCM Referral Form
Adult BCM Referral Form
D&A Case Management Referral Form
F/ACT Referral Form
Merakey HIPAA Authorization

Other Forms

Incidence Reporting

Smith’s PCH RESPITE
BCBH Authorization Request Form

Pressley Ridge
Pressley Ridge HIPAA Authorization

Warmline of Beaver County – MHA in Beaver County

The Warmline of Beaver County is a call-in service providing peer support to individuals with mental illness, their families, and friends.  Anyone calling the Warmline will have someone to talk to, and have the opportunity to discuss problems and access resources.

Local: 724.775.9507
Toll Free: 877.775.WARM (9276)
Hours:  365 days per year from 6 p.m. to 9 p.m., including holidays

Warmline Peers – Permission to Contact

Mental Health Association  (MHA)

Need a partner in health and recovery?  Specialized therapeutic interactions are delivered by Certified Peer Specialists (CPS) who are trained to support individuals in their recovery and involvement in the community.

You will need both a Doctor’s Recommendation Form and an Application for Peer Support to apply.  A recent Psychiatric Evaluation is necessary as well, as it speeds up the intake process.

Call  724.775.9507 if you have any questions.

Doctor’s Recommendation for Peer Support Services
Application for Peer Support

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