Referral Interest Form

Thank you for your interest in RHA Health Services!

This form is for those seeking disability services in Georgia, North Carolina, Pennsylvania, or Tennessee. In addition, if you are seeking services from PAHrtners Deaf Services, a division of RHA Health Services in Pennsylvania, complete all required fields notated with an asterisk. If there is a field or question you do not understand, please select "Unknown."

Please email supporting documents (i.e., psychological evaluation, Behavior Support Plan (BSP), Individual Support Plan (ISP), and Individualized Education Program (IEP)) to the email address for the state where you are seeking services:

North Carolina:

If you need mental health, substance use services, or assistance, please contact the RHA Call Center at 1.800.848.0180.


Applicant Information

Please enter the DOB in the format "MM/DD/YYYY". If you don’t know the precise date, please enter January 1st.
Applicant’s current physical address
Please enter the phone number in the format "123-456-7890"
Please enter the phone number in the format "123-456-7890"

Funding Information

Contact Information for Referral Source

Who can we contact with additional questions?

Please enter the phone number in the format "123-456-7890"