Please fill out the information below if you are a primary care provider (PCP)

• who treats children
• who is enrolled in DCPAP
• who would like to set up consultation or seek resources with the Delaware Child Psychiatry Access Program (DCPAP).

A program coordinator or behavioral health specialist from our team will reach out to you and arrange for an orientation at your earliest convenience.

Enter Service Request Information:

Provider's Name

Provider's Phone Number

How would you like to be contacted? Select Telephone Text Message Email

Please provide your email address

Type of Service Request

• Consultation
• Referral Assistance
• Resource Assistance

Patient's Year of Birth (YYYY)

Patient's Gender

• Male
• Female
• Unidentified

Issue of Request

• Diagnosis
• Treatment
• Medication Management
• Other

Date/Time Submitted

Submit

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