PCSI External Referral Form
Please complete the information below as completely as possible. Submitting this form does not guarantee enrollment in PCSI's services. PCSI staff will review the referral and make every effort to contact the referred individual to discuss their needs, assess eligibility, and determine the most appropriate services or resources. Referrals may only be submitted with the individual's knowledge and consent.
Referring Agency & Staff Information
Please provide the contact information for the staff member submitting this form. This information will be used if PCSI needs clarification or additional information regarding the referral.
Agency Name
*
Staff Member Name & Title
*
Staff Member Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Staff Member Email
*
example@example.com
Customer Eligibility Checklist
To help us serve customers more efficiently, please answer the following eligibility questions based on the information available to you. This information will assist our staff in assessing program eligibility and identifying the most appropriate services for the referred individual.
1. Is the referred individual a resident of the City of Pittsburgh?
*
Yes
No
Unsure
Click here to view
2026 Federal Poverty Guidelines
2. Is the referred individual's household income at or below 200% of the Federal Poverty Level?
*
Yes
No
Unsure
3. Does the referred individual have current or prior criminal justice system involvement (arrest, conviction, probation, parole, incarceration, etc.)
*
Yes
No
Unsure
4. Has the individual agreed to be contacted by PCSI?
*
Yes
No
Customer Information
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of PCSI Service Needed (Please Select All That Apply)
*
Case Management
Pardon & Expungement
Re-Entry Services
Food Assistance
Utility Assistance (Through Dollar Energy, LIHEAP, CAP)
Employment Support
Other
Brief Description of Customer Needs
Please describe the potential customer's current needs, barriers, and goals; providing detailed information helps PCSI determine the most appropriate services and resources.
Customer Consent & Information Sharing
Please confirm the following before submitting this referral:
*
I confirm that the client has been informed of and agrees to this referral and consents to being contacted by Pittsburgh Community Services, Inc. (PCSI) for follow‑up regarding services.
Signature
*
Submit
Submit
Should be Empty: