HAP Referral Form

HAP Referral Form
Heartland Assistance Program Referral Form

*** You may also fax this form to our office and the client will receive a call back to set up an intake appointment**

West Des Moines phone: 515 331 0303/Fax: 515 331 9086

Pella phone: 641 628 9599/Fax 641 621 1493
Name of Referring Organization
Leader referring the potential client
Date of the Referral

MonthDayYear
Date
Name of Client
Date of Birth

MonthDayYear
Date
Telephone Number
Why is the client being referred for mental health counseling?
Does the referred client have private health insurance with a Mental Health Benefit?

YesNo
If yes, please provide the following:
Name of the Insurance Provider
Member ID#
Group ID
Policy Holder's Name
Policy Holder's Date of Birth

MonthDayYear
Date
If no, the organization is committed to:

PARTIALLYFULLY
This organization is committed to partially/fully funding the referral's counseling for a duration of: (number of sessions)*
If the client decides to continue with additional sessions after the determined amount of sessions, the client may either seek more financial assistance from the referring facility or they may have to fund their own counseling. If the organization elects to partially fund the referral's counseling, it is assumed that the client has been advised of their responsibility to pay a portion of the bill prior to their intake at Heartland Christian Counseling.

The signatures below indicate that this form has been reviewed between a representative of the Leadership of the Organization and the potential Client being referred to for counseling at Heartland.
Signature of Church Leadership

Clear
Signature Client or Guardian (if under 18)

Clear
*** May also fax this form to our office and the client will receive a call back to set up an intake appointment**
Should be Empty: