HMH Referral Form

Harmony Mental Health Inc.

Thank you, for choosing us as your pathway to Harmony.
Date

MonthDayYear
Date
Is this referral for a Minor or Adult?*

MinorAdult
Referral Source *
Access Code
Pre-assigned Access code.
How did you hear about us? *
At any time during this process you may save your progress by selecting "save." At which point you will be prompted to create an account & provide your email address. A link to this referral will be emailed to you. However, if you do not have an active email address, we do suggest that you complete this referral in one of our 3 office locations or call-in to have our referrals team assist you in your submission.

Harmony Referral Disclosure

Please read carefully prior to agreeing to the terms and conditions

Referral Source Information
Company Name
Agency/school/institution making the referral
Your Name *

First NameMiddle NameLast Name
Position/Title
Relationship to Prospective Client
Referral Source Email *
example@example.com
Main Number*
Please enter a valid phone number.
Alternative #
Please enter a valid phone number.
Fax #
Please enter a valid Fax# number.
How will you provide proof of Release of information authorization today?

Harmony Authorization FormUpload Authorization Form
Please upload signed authorization form(s)

Please export to PDF prior to uploading
Cancelof
HMH Authorization Form. Please download fillable PDF and upload above when completed and signed.

Parent &/or Legal Guardian

Referral Source
Parent/Guardian Name #1 *

First NameLast Name
Relationship to Client *
Parent/Guardians legal relationship to the prospective client
Parent/Guardian Name #2

First NameLast Name
Relationship to Client
Parent/Guardians legal relationship to the prospective client
Has the minor ever been the subject of a custody agreement, adoption or have any other custody or guardianship changes occurred?*

YesNoNot to my knowledge
Types of Custody/Guardianship*

Legal CustodyPhysical CustodySole CustodyJoint CustodyIn-States Custody
Notes on Custody/Guardianship
Please provide any additional custody or guardianship information here.
Please upload proof of custody/guardianship

Please export to PDF prior to uploading
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Address & Contact Information
County of Residence *
Homeless?

Yes
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Contact Method

CallTextEmail
Are we allowed to leave a message?

YesNo
Client or Guardian email *
example@example.com
Main Number*
Best number to reach you
Alternative Number
Alternative number
ID Card (Front/Back) *

Please upload Front & Back of Formal ID. Please export to PDF prior to uploading
Cancelof

Insurance & Billing Information
Are you able to provide information on how treatment will be covered?

YesNo
What Resources are Available to Pay for Treatment?*

InsuranceDHHROut-of-PocketMedicaid/MCOCourt Order

Before you go...

Please review and make any necessary edits/uploads to your referral. If you are good to submit the referral form, please take a moment to read and sign the below statement of confirmation.
Please upload any additional documentation Now.

Please export to PDF prior to uploading
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I Your Name * confirm that I have the legal right or received consent from the referred or their guardian to make this referral. To my knowledge all information that has been provided is both accurate and within my right to release.
Referral Source Signature *

Clear

SUBMIT REFERRAL
IMPORTANT

Once you select "Submit" please DO NOT refresh or close your browser page until you have been redirected to the confirmation page. Please understand that if by any chance you do refresh or close the browser the referral may duplicate or become corrupted only providing partial information, this may result in a processing delay of the referral.
Please verify that you are human*
Should be Empty:

Prospective Client Info.	Parent &/or Legal Guardian Info.
Full Name	Full Name
Demographic Info.	Proof of Custody &/or Guardianship
SSN #	Address & Contact Info
Insurance card	Formal ID
Prior Treatment History

Harmony Referral Disclosure