Behavioral Health Services

LOCATIONS

Mechanicsburg

5000 Ritter Road
Mechanicsburg, PA 17055

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

Lancaster

163 W Fredrick Street
Lancaster, PA 17551

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

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

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