System of Care is here to provide the right support at the right time for children and youth facing emotional, behavioral, or mental health challenges. If you know a child or adolescent who may benefit from coordinated services, making a referral is the first step toward getting them the help they need.

Eligible children and youth (ages 5–21) may be experiencing severe emotional disturbances, needing multiple services, or facing challenges that impact their daily lives. Families struggling with complex service plans, communication difficulties, or frequent hospitalizations may also qualify for support.

Referrals can be made by anyone connected to the child, including family members, school personnel, service providers, or the child themselves. Simply complete the secure online referral form, and a System of Care team member will follow up to discuss the next steps.

Take action today! Submit the below referral form to help connect a child or family to the resources they need.

Is this a Referral for the Family Voice Matters Support Group? *

(If yes, please skip the youth contact information portion below.)

Yes

Youth Contact Information

Is the Youth Interested in Participating?

Yes

Youth Name

First Name

Last Name

Youth Age

In which School District does the youth live?

Phone

(###)

###

####

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Time to Contact

Morning

Afternoon

Evening

Caregiver Contact Information

Is the Caregiver Interested in Participating?

Yes

Caregiver Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Time Contact

Morning

Afternoon

Evening

Notes:

Please include any additional information that may be helpful for the interviewer when contacting the youth and caregiver, i.e., more specific time to contact them, best way to contact them (call and/or text), language barriers, safety concerns, etc.

Referring Agency/Individual Information

Name of Referring Agency/Individual

Contact Person

First Name

Last Name

Phone

(###)

###

####

Email *

Current Service Providers (if any)

Please list any current service providers involved in the client’s care:

Additional Information

Please provide any additional information that may be relevant to the referral:

Other Children Associated with this Referral:

Name

First Name

Last Name

Age

Name

First Name

Last Name

Age

Name

First Name

Last Name

Age

Name

First Name

Last Name

Age

Mental / Behavioral Health Information

Was the youth screened or assessed for trauma-related experiences?

Yes

Don't Know

If the youth WAS NOT screened or assessed for trauma-related experiences, please select why:

No time during interview

No training around trauma screening/disclosure

No institutional/organizational policy around screening

No referral network and/or infrastructure for trauma services currently available

Other

If the youth WAS screened or assessed for trauma-related experiences, was the screen positive?

Yes

Don't know

Did the youth have a positive suicide screen?

Yes

Don't Know

If the youth DID have a positive suicide screen, was a suicidal safety plan developed?

Yes

Don't Know

If the youth DID have a positive suicide screen, was access to lethal means assessed?

Yes

Don't Know

Youth Mental Health Diagnoses

Primary:

Secondary:

Tertiary:

Consent

By clicking 'Submit Referral Now' below, I confirm that I have the client's consent to make this referral to the System of Care program.

Thank You for Your Referral!

Your submission has been received. A System of Care team member will review the referral and follow up soon to discuss next steps.

If you have any immediate questions or need further assistance, please feel free to contact us.

Together, we’re making a difference for children, youth, and families in need. Thank you for helping connect them to the support they deserve!

33 W. 3rd Street, 4th Floor
Williamsport, PA 17701
(570) 326-7895

Office Hours
Monday - Friday
8am - 4:30 pm

This website was developed under grant number 6H79SM087729-01M001 under the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The views, policies and opinions expressed are those of the author and do not necessarily reflect those of SAMHSA or HHS.

Lycoming-Clinton Joinder Board complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.