Pathways to Wellness Staff Name* First Last Screening Date* MM slash DD slash YYYY Work Location CountyColumbiaCumberlandJuniataLebanonMifflinMontourNorthumberlandPerrySnyderSomersetUnionWIC PID #* Referred for Brief Intervention* Yes No Declined If YES, scan and email paper screening form and complete section below.For Brief Intervention Referral OnlyIf the screening indicates a need for a Brief Intervention complete the information below and scan/email completed screening paper form to the Program Manager.Client Name* First Last Date of Birth* MM slash DD slash YYYY Phone*Texting OK?* Yes No Best Contact Time:* Race*Select OneAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More RacesRace Not ReportedHispanic/Latino* Yes No Preferred Language* English Spanish Mandarin Arabic Client Type:* Pregnant Postpartum If Pregnant, Trimester:* 1st 2nd 3rd County of Residence*Select OneColumbia CountyCumberland CountyJuniata CountyLebanon CountyMifflin CountyMontour CountyNorthumberland CountyPerry CountySnyder CountySomerset CountyUnion CountyAdams CountyAllegheny CountyArmstrong CountyBeaver CountyBedford CountyBerks CountyBlair CountyBradford CountyBucks CountyButler CountyCambria CountyCameron CountyCarbon CountyCentre CountyChester CountyClarion CountyClearfield CountyClinton CountyCrawford CountyDauphin CountyDelaware CountyElk CountyErie CountyFayette CountyForest CountyFranklin CountyFulton CountyGreene CountyHuntingdon CountyIndiana CountyJefferson CountyLackawanna CountyLancaster CountyLawrence CountyLehigh CountyLuzerne CountyLycoming CountyMcKean CountyMercer CountyMonroe CountyMontgomery CountyNorthampton CountyPhiladelphia CountyPike CountyPotter CountySchuylkill CountySullivan CountySusquehanna CountyTioga CountyVenango CountyWarren CountyWashington CountyWayne CountyWestmoreland CountyWyoming CountyYork CountyReferral Type*Substance Abuse TreatmentSmoking CessationMental HealthAlcoholDomestic AbuseNotes: Δ
