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****Please have your insurance information 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
*
-
Month
-
Day
Year
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Client Details
Contact information for the Client
Are you being referred though the Department of Corrections?
*
Yes
No
Client Details
Contact information for the Client
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
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Social Security Number
*
For Insurance purposes
Are you under age 18?
*
Yes
No
Please enter parent/guardian name
*
Parent/Guardian Name
Gender
*
Male
Female
Transgender Male
Transgender Female
Non-binary / Gender Non-Conforming
Prefer Not to SAy
Sexual Orientation
*
Heterosexual/Straight
Gay/Lesbian
Bisexual / Pansexual
Prefer Not to Say
Ethnicity
*
African American
Latino
Asian/Pacific Islander
Native American
White
Mixed Race/Ethnicity
Declines to state/unknown
Other
Address
*
Address
Indirizzo Riga 2
City
Nazione / Provincia
Post Code
Phone number
*
Best Contact Phone Number
Okay to leave Msg?
*
Yes
No
Alternate Phone Number
Alternate contact phone number
Okay to leave Msg?
*
Yes
No
E-mail
*
Confirmation Email
confirm email address
Guardian email
*
Confirmation Email
example@example.com
Do you receive Medical Assistance/Medicaid
*
Please Select
YES
NO
MA Policy Number
*
10-digit MA Number
Do you have medical coverage?
*
Yes
No
Health Insurance
*
Name of Health Insurance
Policy Number
*
Do you have additional medical coverage?
*
Yes
No
Health Insurance
*
Name of Health Insurance
Policy Number
*
Are you a parent/guardian of a child under the age of 18?
*
Yes
No
Does the child reside in the home?
*
Yes
No
Index Crime/Trauma
Details About The Trauma
Index Crime
*
Sexual Assault
Domestic Assault
Physical Assault
Human Trafficking
Gender Based Violence
Stabbing
Shooting
Vehicular Assault
Family of Victim
Witnessed Homicide
Witnessed Assault
Refugee/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/Ideation
Dangerous/Risky/Impulsive Behavior
Self-injury
Physical Aggression
Homicidal Attempts/Ideation
Psychosis/Psychotic Behavior
No current risk factor
Is the client able to give consent
*
Yes
No
Please upload any supporting documents
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