School staff are encouraged to use the form below to make referrals for School-Based Outpatient Therapy. Please be sure to follow your school’s protocol for making referrals. Questions regarding availability should be directed to our Intake Coordinator, Wanda Koontz –, (717) 422-6440 option 8. Custody orders and signed release of information forms can be faxed to (717) 620-0536.

Instructions for completing release forms: Be sure the release is signed by the correct person (parent/guardian if under 14, student if 14 or older). Check the boxes for any additional information that the signer would like shared. The person requesting the release must also sign and then write their name and SMSD where indicated.

Here are informational letters you can share with families who are referred for school-based: