Wagner Behavioral Health Services, LLC
Wagner Behavioral Health Services, LLC

New Client Forms

New patients will need to fill out several forms before therapy can begin. To make the process as smooth and efficient as possible, we provide the most important documents as downloads right here on our website.

 

Select the appropriate forms you will need, print the documents and return the completed documents to our practice in person at your first scheduled appointment. All forms are also available at the practice; however, filling them out in advance saves time.

 

Referral forms are also availble for download.
 
If you are unsure which forms to fill out, don't hesitate to contact us.

All Client Forms

To be completed by an adult and/or parent/guardian.

New Client Demographic Information
Contains demographic information such as address; telephone; work and family; emergency contact and other important information.
Client Demographic Information Form_Upda[...]
Adobe Acrobat document [71.8 KB]

Adult Forms

To be completed by an adult or a representative accompanied by the adult.

Adult Checklist of Concerns
Contains list of concerns related to an adult that would be relevant to treatment.
Adult checklist of concerns_Updated JULY[...]
Adobe Acrobat document [45.3 KB]

Young Adult Forms (Age 13-17)

To be completed by the young adult.

Young Adult Information
To be completed by the young adults ages from 13 to 17 years.
Young Adult Information Form_Updated JUL[...]
Adobe Acrobat document [67.9 KB]

Child/Adolescent Forms

To be completed by the primary/legal guardian of the child.

Child Development History
Contains child developmental history as it relates to treatment.
Child developmental history_Updated JULY[...]
Adobe Acrobat document [49.4 KB]
Child Checklist of Concerns
Contains a checklist of concerns for a child that can be relevant for seeking services with Wagner Behavioral Health Services,LLC.
Child Checklist of concerns-UPDATED JULY[...]
Adobe Acrobat document [72.4 KB]

Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.

Where to Find Us:

Wagner Behavioral Health

Services, LLC

1001 State Street, Suite 1300

Erie, PA 16501

(814)580-1743

To Make An Appointment or Referral Call:

Main Office:

Erie

(814) 580-1743

 

Titusville/Warren

814-827-2218  

           

  Fax:  814-271-7262

  *Limited to 20 pages per transaction

Office Hours

REGULAR OFFICE HOURS:

 

Tuesday through Friday

9:30 a.m. to 5:30 p.m

 

Appointments may be provided outside of normal business hours by necessity only.

 

This office is closed on major holidays.

 

Our Locations

Main Office: 

(ERIE)

1001 State Street

Renaissance Center

Erie, PA  16501

(814) 580-1743

(814) 271-7262 (Fax)

 

(WARREN)

285 Hospital Drive

North Warren, PA  16365-4886

(814) 827-2218

(814) 271-7262 (Fax)

 

(TITUSVILLE) 

115 South Washington Street

Titusville, PA  16354-1767

(814) 827-2218

(814) 271-7262 (Fax)

 

Patient Forms

New patient? Save time and reduce the amount of paperwork you have to fill out at your first visit. We provide several forms as PDF download on our site.

Referral Forms

Click here for our referral forms.

Client Feedback

If you would like to participate in helping us provide you with the best therapy by giving us your feed back. Click here to fill out our form.

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