Forms

For best results, please download forms and view with Adobe Reader.

Forms are applicable to All Counties unless otherwise specified.

Please submit completed forms via fax or secure email to the appropriate county:


Allegheny: 888-251-0087 CCBH_ICPAllegheny@ccbh.com
Blair: 855-480-7029 CCBH_ICPBlair@ccbh.com
Bedford/Somerset: 833-622-3982 CCBH_ICPBS@ccbh.com
Delaware: 833-995-2002 CCBH_ICPDelawareCo@ccbh.com
Carbon/Monroe/Pike: 866-562-2405 CCBH_ICPCMP@ccbh.com
Chester: 888-589-6559 CCBH_ICPChester@ccbh.com
Erie: 855-892-8495 CCBH_ICPErie@ccbh.com
Lycoming/Clinton: 855-346-7318 CCBH_ICPLC@ccbh.com
Northeast Moosic:

Lackawanna, Luzerne,
Susquehanna, Wyoming

866-284-9184 CCBH_ICPNE@ccbh.com
North Central Dubois:

Cameron, Clarion, Clearfield,
Elk, Forest, Jefferson,
McKean, Potter, Warren

866-294-1142 CCBH_ICPNC@ccbh.com
North Central Moosic:

Bradford, Columbia, Montour,
Northumberland, Schuylkill, Snyder,
Sullivan, Tioga, Union, Wayne

866-558-2618 CCBH_ICPNC@ccbh.com
North Central Pittsburgh:
Greene
888-251-0087 CCBH_ICPNC@ccbh.com
North Central State College:

Centre, Huntingdon, Juniata, Mifflin

866-562-2406 CCBH_ICPNC@ccbh.com
York/Adams/Berks: 866-418-0366 CCBH_ICPYAB@ccbh.com

FBMHS are evaluation and treatment services provided to a specific child in a family, but focuses on strengthening the whole family system to increase their ability to successfully manage their child's behavioral and emotional issues. Services are provided by licensed agencies employing a mental health professional and a mental health worker as a team to provide treatment and case management interventions. Services are provided in the home of the family.

Intensive Behavioral Health Services (IBHS) is an array of therapeutic interventions and supports provided to a child, youth, or young adult in the home, school, or other community setting. Under IBHS, qualified and licensed providers can offer individual, group, ABA, and evidence-based treatments for children and youth. OMHSAS has created an IBHS website and training link where you can find recordings of OMHSAS trainings, links to forms, and important information about becoming a licensed IBHS provider, as well as frequently asked questions. Providers are encouraged to check this IBHS website for up-to-date information.

Please reference the IBHS Packet Checklist below for timeframes and packet requirements.

RTF services are comprehensive mental health treatment services for children with severe disturbances or mental illness. These services are provided in Residential Treatment Facilities (RTFs) which must be licensed by OCY&F under Chapter 3800. The facility must have a service description approved by OMHSAS, be certified by OMHSAS through annual on-site review, have a utilization review plan in effect and be enrolled in the MA program.

Providers are encouraged to report SMIs to Community Care via the ePortal. For more information, see our guide.