Adult PSS Referral Form

Adult Referral Form

First Name (required)

Last Name (required)

Preferred Name (required)

Birth Date (required)

Gender (required)

Social Security Number (required)

Cell Phone

Home Phone

Address 1

Address 2

City

State

Zip

Release of Information

I give my permission to have my name/ my child’s name and contact information released to the Mental Health Association of Franklin and Fulton Counties so that I may be contacted to discuss participation in Peer Support Services.

Agree/Disagree for MHAFF to Contact Peer (required)

Referring Agency (required)

Referring Agency Contact Name (required)

Referring Agency Contact # (required)

How did you hear about us? (required)

Mental Health Association of Franklin and Fulton Counties
144 South 8th St., Suite 111
Chambersburg, PA 17201
Phone: 717-264-4301
Fax: 717-264-3591