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The Warrior Project Referral Form

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In order to be referred to the program, a youth must:

Have a mental health diagnosis
Be eligible for and enrolled with PerformCare (Medical Assistance)
Show a need to gain skills in at least two of the four target domains: employment, education, independent living skills, and community involvement and socialization
Be 16-23 years old (discharge occurs prior to 24th birthday)-allow 1 year for program completion
Be able to be left alone without supervision in the community (at the store, for example) and at home for more than a few minutes at a time and remain safe.
Be able to complete the following tasks independently without any safety concerns or significant limitations: riding the bus, grocery shopping, meal prep and cooking.

THE FOLLOWING MUST BE INCLUDED FOR REFERRAL TO BE ACCEPTED:

Documentation of Diagnosis | “Documentation of diagnosis” refers to documentation that the participant has a mental health diagnosis that qualifies him/her for the program.
MH/ID/EI Release | *This form is required if the participant has an Intellectual Disability (ID) or Autism Spectrum Disorder (ASD) diagnosis in addition to their mental health diagnosis, as they are reviewed on a case by case basis.* | Please find the release form here
Warrior Project Release | **Required for all other participants**| Please find the release form here

REFERRALS WILL BE REVIEWED TO DETERMINE PROGRAM ELIGIBILITY PRIOR TO SCHEDULING AN INTAKE.

To speak with our staff directly, call 717-450-5666 Ext 2302, or fill out our online form below and we will call you to follow up.

Date of Referral *

Name *

Address (Line 1) *

Address (Line 2)

City *

State *

Zip Code *

Phone Number *

Email *

Date of Birth *

Social Security Number

11 of 11 Character(s) left

MA Recipient / State ID Number *

Does the participant have Non-MA Primary Insurance? *

Does the participant have a caregiver? *

Caregiver(s) Name

Caregiver's Email

Primary language spoken by participant *

Other languages spoken by participant

Please list at least 2 goals the participant wants to work on to increase independence in the following areas:

Does the participant have transportation (other than MATP/CAP) or a way to get to the warrior project groups and activities?

Is the participant currently a student? *

School District

Grade

Building/Educational placement (Ex: CTC)

Other Social Service Agencies Involved (Select all that apply)

Name of Agency/Person Referring Participant *

Phone Number of Agency/Person Referring Participant *

Email of Agency/Person Referring Participant *

Please attach the following:(Files accepted: doc, docx, pdf, png, jpg, jpeg)