Make A Referral

Helpful Links:

Referral Request Form

To talk to our patient registration staff directly, call 1-855-272-1653, or fill out our online form below and we will call you to follow up.

Name

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Phone Number

Date of Birth (Format: YYYY-MM-DD)

Does the client have health insurance?

Does the client have supplemental/secondary insurance or medical assistance products (PerformCare, CCBHO, Etc)?

Yes - *Please be aware that we do not accept Medical Assistance Products, but we can discuss your other options.*
** To view programs at our Parent Company, Pennsylvania Counseling Services, for MA Products, visit pacounseling.com/referrals.** No

Please select the preferred appointment type

Please select the preferred location for appointments

Please select the preferred provider

Reason for seeking treatment?

Name of Agency/Person Referring Patient

Phone Number of Agency/Person Referring Patient

Email of Agency/Person Referring Patient

Please attach the following:

Insurance Card(s)
Medication Lists (If any)
Medical Records
Completed Release of Information Form

I confirm that I would like to schedule an appointment with LiveUp Counseling

Agree

PLEASE NOTE THE FOLLOWING:

Completing this form is not a guarantee that we will be able to schedule an appointment for you.
If you are currently receiving services somewhere else, your insurance provider might consider this a duplication of services. Our staff will help determine if that is the case.
If you do not have health insurance, our staff will explain what other funding options may apply to you, including Self-Pay rates. We can call you Mon-Thur 8AM-5:45PM, or Fri 8AM-4:45PM.

Make A Referral

Helpful Links:

Referral Request Form

PLEASE NOTE THE FOLLOWING:

Additional Links

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