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IN CRISIS?

ART FOR CHANGE

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PRE-REGISTER

If you are experiencing a crisis please call Re:solve Crisis Network at 1-888-796-8226 or 988 (suicide or crisis hotline)

Thank you for contacting Persad Center. If you are interested in accessing our services, please fill out the pre-registration form below.

One of our Intake Coordinators will contact you within 2 business days to discuss the next steps in your registration process.

Pre-Registration Form

Contact Information:

Full Name

Birthday

Phone

Pronouns

ZIP code

Brief description of your need for services:

description

Have you completed a higher level of care in the last 60 days (Psych Hospital, Partial or IOP)?

Yes

If Yes, describe.

Are you looking for:

Mental Health Treatment

Substance Use Treatment

Dual Diagnosis Treatment

Are you currently in therapy?

Yes

What kind of services are you looking for?

Individual therapy

Psychiatric services (available with therapy only)

Both

Is this for a court ordered assessment?

Yes

Is this for a pre-surgical mental health evaluation?

Yes

Do you have health insurance?

Yes

If Yes, what Insurance do you have?

If No, please visit www.compass.state.pa.us to apply.

If you have any questions, please give our intake department a call at 412-441-9786 extension 226

By choosing this option, you have agreed to share your information with Persad Center. The information contained in this transmission is privileged and confidential and/or protected health information (PHI) and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA).