IHCS Self-Referral Form

"*" indicates required fields

Participant Full Name*

Select The Office Closest To You*

Northeast PA - 24 North River Street, Wilkes-Barre, PA 18702

Central PA - 2112 Walnut Street, Harrisburg, PA 17103

Southwest PA - 1650 Main Street #1, Pittsburgh, PA 15215

Primary Contact Name*

Primary Contact Relationship to participant*

Primary Contact Phone Number*

Primary Contact Email Address*

Does the participant have a waiver through the office of developmental disabilities?

Yes

Additional Information