TRC Referral form

****Please have client present and/or information available to complete referral****
CCTH

Central PA Center for Trauma and Healing-A Treatment Recovery Center (TRC)-a program of HALA Inc.
A Program of the Harrisburg Area Learning Academy, Inc.
Date*

MonthDayYear
Referring Agency

Contact information on referring Agency
Referring Agency*
Name of Referring Agency
Is this a Department of Corrections Referral?*

YesNo
Address of Referring Agency*

Street Address

Street Address Line 2

CityState

Zip Code
Agency Representative*

First NameLast Name
Agency Representative's Phone Number*

Area CodePhone Number
Email*

Confirmation Emailconfirm email address
Client Details

Contact information for the Client
Client Name*

First NameLast Name
Enter Client's Initials (i.e. D.G.)*
Date of birth*

MonthDayYear
Social Security Number *
No dashes
Is the client under the age of 18?*

YesNo
Please enter parent/guardian name *
Parent/Guardian Name
Gender*

MaleFemaleTransgender MaleTransgender FemaleNon-binary / Gender Non-ConformingPrefer Not to SAy
Sexual Orientation*

Heterosexual/StraightGay/LesbianBisexual / PansexualPrefer Not to Say
Ethnicity*

African AmericanLatinoAsian/Pacific IslanderNative AmericanWhiteMixed Race/EthnicityDeclines to state/unknownOther
Client Address*

Address

Indirizzo Riga 2

CityNazione / Provincia

Post Code
Client phone number *
Best Contact Phone Number
Okay to leave Msg?*
Alternate Phone Number
Alternate contact phone number
Okay to leave Msg?*
Client E-mail*

Confirmation Emailconfirm email address
Guardian email*

Confirmation Emailexample@example.com
Does the client receive Medical Assistance/Medicaid*
MA Policy Number*
10-digit MA Number
Does the client have medical coverage?*
Health Insurance*
Name of Health Insurance
Policy Number*
Does the client have additional medical coverage?*
Health Insurance*
Name of Health Insurance
Policy Number*
Are you a parent/guardian of a child under the age of 18?*

YesNo
Does the child reside in the home?*

YesNo
Index Crime/Trauma

Details About The Trauma
Index Crime*

Sexual AssaultDomestic AssaultPhysical AssaultHuman TraffickingGender Based ViolenceStabbingShootingVehicular AssaultFamily of VictimWitnessed HomicideWitnessed AssaultRefugee/Outside of U.S. trauma (torture, war trauma)
Year Trauma Occurred (it can be an estimate)*
Type Year that Incident(s) occurred
Risk Factors

Client Risk Factors
History of or currently:*

Suicidal Attempts/IdeationDangerous/Risky/Impulsive BehaviorSelf-injuryPhysical AggressionHomicidal Attempts/IdeationPsychosis/Psychotic BehaviorNo current risk factor
Is the client able to give consent*
Please upload any supporting documents

Carica un File

Cancelof
Should be Empty:

CCTH

Referring Agency

Client Details

Index Crime/Trauma

Risk Factors