Contact Southwestern Human Services

Southwestern Human Services, a non-profit organization providing quality mental health services for adults, children, adolescents and families in the southwestern Pennsylvania area.

Southwestern Human Services
110 Fort Couch Road, 2nd Floor
Pittsburgh, PA 15241
Phone: (412) 831-1223

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Southwestern offers a variety of programs for adults, children, adolescents and families in the southwestern Pennsylvania area.

Contact Southwestern Human Services

Feel free to contact us at the address or number below with any questions you have about any of our services. Thank you.

Southwestern Human Services
110 Fort Couch Road
2nd Floor
Pittsburgh, PA 15241
Phone: (412) 831-1223
Fax: (412) 831-1034
SHS Map/Directions

Referral Form

This form can be completed by human service agencies or consumers. Southwestern Human Services strictly follows the guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The contents of this electronic communication are protected by state and federal law. This priveledged and confidential information is intended only for use by SHS staff to fulfill your request.

Referral Source	Date
E-mail Phone	Fax
Client Name	D.O.B.
Legal Guardian (if applicable)	Relationship
Client Home Address	Home Phone
May we contact the client's legal guardian? Yes No
Do you have Private Insurance? Yes No
Insurance Company name
Are you uninsured? Yes No
IDENTIFIED CONCERNS (check all that apply) Self-Abusive Self-Stimulating Sexual Acting Out Physical Aggression Verbal Aggression Defiant Oppositional Fire Setting Animal Cruelty Psychoticism Visual Hallucinations Auditory Hallucinations Suicidal Ideation/Threats Suicidal Acts Homicidal Ideation/Threats Homicidal Acts Poor Social Skills Poor Problem Solving Skills Poor Anger Management Poor Communication Skills Hyperactive Property Destruction Gang Involvement Truant Legal Problems Education/Vocational Problems Education/Vocational Deficits School/Work Refusal Family Conflicts Peer/Sibling Conflict Probation/Curfew Violation Obesity Enuresis Encopresis Anxiety Separation Anxiety Impulsivity Echolalia Seizures Medical Concerns Withdrawn Isolation Sleep Disturbance Low Self-Esteem Depression Alcohol Use/Abuse/Dependency Chemical Use/Abuse/Dependency/Selling DUI Other:
SERVICE NEEDS (check all that apply) Intake/Assessment Psychiatric Evaluation Psychological Evaluation Psychiatric Medication Evaluation Individual Therapy Family/Collateral Therapy Group Therapy Community Support Group Other: