Notice

In order to respond to your request, you will need to provide us with confidential health information. Before proceeding with this referral form and patient family history form, please download our Notice of Privacy Practices and review our Disclaimer Statement. By using these forms you are agreeing to be bound by both the Notice of Privacy Practices and the Disclaimer Statement. Foundations Behavioral Health is committed to maintaining its patients' privacy. We will use the information you provide only to help us respond to your query.

We have put in place appropriate physical, electronic and administrative procedures to safeguard the information we collect from you. If you have indicated that you would like to receive a response from us via e-mail, you are authorizing us to respond to you with an unencrypted e-mail that may contain private information. If you are uncomfortable submitting this information electronically or receiving a response from us via e-mail, please call us at 215-340-1500 ext. 261.

We will make every effort to respond to your request within the next 2 business days. Should you not receive response or an e-mail confirming that we have received your information within that time, please re-submit your information, or call 215-340-1500 ext. 261.

Note: if you have symptoms of an urgent nature, please call your doctor or go to the nearest emergency room immediately.