Mobile Trauma Therapy Self Referral – Community Health Council of Lebanon County

Name *

Age *

Phone *

Email *

Gender *

Male
Female
Other/Decline to Answer

Race/Ethnicity *

Preferred means of contact *

Phone
Email

Is it ok to leave a detailed message on your phone or email? *

Yes
No

Reason for your interest in mobile trauma therapy:

Please note: Webforms are not considered confidential communication. Information on this form will be saved on the Community Health Council’s website, and will be sent to both the Director and the Connected Together Coordinator. If confidentiality is a concern, please call Caitlin Lockard at 717-270-6972 x360 to make your referral.