Click here to learn how to get effective treatment started quickly and easily with virtually no "waiting" if you live in Philadelphia or your child doesn't already have PA Medicaid (Medical Assistance) benefits....

To request services for your child:

Download this Referral form (.pdf format)

You will need   to view of this .pdf document

To preserve the confidentiality of your personal information,

do not return this form on-line

You can fax or mail the form to us.