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

Referral Forms

The referral forms may be downloaded and printed. They are to be completed by the person requesting services from WBH.  The forms can be faxed or mailed to our office.   

 

You can contact our office and someone will be happy to help you with any questions you may have with the referral form.

Behavioral/Mental Health Referral Form

Behavioral/Mental Health Referral Form
To be completed by referring providers or facilities requesting outpatient mental/behavioral health services for a client or patient.
WBHS Client Referral Form_updated JAN 20[...]
Adobe Acrobat document [97.4 KB]

Adult/Juvenile SOP Referral Form

Adult/Juvenile SOP Referral Form
To be completed by referring agents, officers, providers, and/or facilities requesting sex offender services.
WBHServices SOP Referral Form_AdultAdole[...]
Adobe Acrobat document [45.8 KB]

Parent Support Group Referral Form

Parent Support Group Therapy Referral Form
For parents in need of support group therapy for whom their children have been victims or offenders of abuse/trauma.
WBHServices NOP Referral Form.pdf
Adobe Acrobat document [27.6 KB]

Drug & Alcohol Referral Form

Drug & Alcohol Referral Form
To be completed by referring agents, officers, providers, and/or facilities requesting services.
WBHS DA Referral Form.pdf
Adobe Acrobat document [27.7 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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