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What We Do

BRIDGES™ Referral Form

Child's Basic Information
First Name *
Last Name *
Child's Gender Identity
Referrer's Contact Number (Required)
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Insurance Information

Note: Our program only accepts clients eligible for Medical Assistance (Medicaid) at this time.

Parent/Guardian Information
First Name *
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
First Name
Last Name
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Guardian's Rights
Child's Background
Has the child been involved with Children and Youth Services?
Has the child been involved with the Juvenile Justice System?
Child's Treatment History (Type N/A if Child has no history)
Risk Management Assessment
Does the child have a history of:
School Information
Is the child currently in alternative education or cyber school?
First Name *
Last Name *
School Contact Phone (Required)
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Does the child have an Individualized Education Plan/504 Plan?
If so, is the IEP/504 Plan for:

 

 

If you are having trouble with the online form, click below to download the form as a document. Once complete, please submit to Devon Bortzfield at dbortzfield@choyork.org.

 

Questions about referrals? Contact Devon Bortzfield, Program Supervisor, at 

717-718-1890 ext 1118 or dbortzfield@choyork.org