Referrals

Mental Health & Substance Use Services Referral

Thank you for considering CenClear for your Mental Health (MH) or Substance User Disorder (SUD) treatment needs.

Interested in services? Please complete the short form below. Include the best phone number and time to reach you, and a member of our team will contact you to help schedule an appointment.

If you have would like assistance completing the form or would like to call directly, please contact us at (814) 342-5848 or toll free at 1-877-341-5848

Referral Source

Who is making this referral?*:
Referral Source Name/Agency (Complete if applicable):
Referral Source Phone Number (Complete if applicable):

Person Being Referred

Legal Name*:
Parent/Legal Guardian (Complete if applicable):
Date of Birth*:

Sex*:

Address

Street Address:
City:
State:
ZIP Code:
County:

Contact Information

Preferred Phone Number*:
Other Phone Number:
Email Address:

Best Time to Call:

Services Requested


Please select ALL services you are interested in. You may select more than one service (Mark all that are applicable with CTRL + Click)
Mental Health Services:
Substance Use Disorder Services:
Community Services:
Peer Recovery Services:

Additional Information


Is the person being referred currently invovled with Children and Youth Services?:

Is the person being referred currently involved with the criminal justice system?:

Is the person being referred currently involved in any other services?:

Privacy & Confidentiality


Your privacy is important to us. No information about you or the person you are referring will be released without proper 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.

Thank you for completing the Referral form for our Behavioral Health Services.

If you have a document you would like to send as an attachment, please email it to intake@cenclear.org and include in the subject line of the email (Referred Person’s Name) and Referral Attachment. If you have any questions or concerns, please contact us at (814) 342-5848 or toll free at 1-877-341-5845.

After you submit this form, a member of the CenClear team will contact you using the information provided.

If this is an emergency, please call 911.

Ready to Submit?


Please review your information before submitting.