Forms
Forms for Adults
Behavioral Health Forms
- ACT Referral Form (PDF)
- Core Referral Form (PDF)
- Extended Acute Care (PDF)
- HealthChoices Housing Referral Form (PDF)
Substance Use Treatment Support Forms
Buprenorphine Coordinator Program
- RASE Project Referral Form (PDF)
- York Buprenorphine Program Admission Criteria (PDF)
- York / Adams Buprenorphine Coordinator Program (PDF)
Recovery Support Services Program
- RASE Project Referral Form (PDF)
- York Recovery Support Services Program Admission Criteria (PDF)
- York Recovery Support Services Program Fact Sheet (PDF)
York / Adams Recovery House / Bridge Support Subsidy
- The Bridge Support/Recovery House Program is a Reinvestment Plan for recovery house room and board subsidies for York and Adams HealthChoices Members. This subsidy has been established to assist HealthChoices Members in need of financial assistance with limited income and assets, and to:
- Continue to support members in their recovery
- Reduce the number of non-hospital drug and alcohol rehabilitation readmissions.
- Increase the individuals' ability to be employed and/or participate in volunteer activities.
- The reinvestment funds for this project provide subsidies in two distinct ways for approved applicants, and the amounts are determined by the York/Adams HealthChoices Management Unit.
- Applications can only be submitted by a case manager with SAM or MH/IDD, Probation Officer (Adult or Juvenile), Children and Youth Case Worker, Drug and Alcohol Commission, RASE Buprenorphine Coordinator, and/or other social worker from a higher level of care.
- Basic Eligibility Criteria includes but is not limited to:
- Individuals (18) years or older; Enrolled in Medical Assistance, and/or be likely eligible for Medical Assistance
- Those with a current documented substance use disorder
- Current residents of either York or Adams County for at least six months
- Individuals with income or assets below 138% of the Federal Poverty Limit and have limited savings and assets
- Individuals able to sustain Recovery House Room and Board with temporary assistance
- Meet the eligibility criteria and be accepted at an approved recovery house
- Individuals connected with a case manager with SAM or MH/IDD, Probation Officer (Adult or Juvenile), Children and Youth Case Worker, Drug and Alcohol Commission, RASE Buprenorphine Coordinator, and/or other social workers from a higher level of care
- The applicant has had a Drug and Alcohol Assessment and a recommendation
- Individuals with limited income and assets
Child and Adolescent Forms
Behavioral Health Forms
Community Residential Rehabilitation (CRR) Room and Board: This subsidy provides room and board payment only for children who are placed out of the home in a CRR and meet eligibility criteria.
- Release of Information for CRR Room and Board (PDF)
- Community Residential Rehabilitation (CRR) Room and Board Application (PDF)
To Learn More About the Subsidy and the Parents / Guardian's Financial Responsibility view our What is the CRR Room 2015 (PDF)
Joint Planning Team - The goal for this process is to ensure that the youth and family are able to independently plan and access the resources they need in the community in order to have the least restrictive placement for youth.
Announcing the Joint Planning Team for Truancy - This pilot project will be accepting referrals from the Office of Children, Youth and Families of York County to work with youth and family to plan for youth to reduce the amount of truant days. The process will utilize the family voice and choice, to identify natural and community supports to address the truant behaviors.
Please see the program announcement: Joint Truancy Announcement September 2016 (PDF)