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  • Harmony Mental Health Inc.

    Harmony Mental Health Inc.

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

    Harmony Referral Disclosure

    Please read carefully prior to agreeing to the terms and conditions
    • Self  
    • Disclosure

      Terms and Conditions for Self Referrals
    • In order to process your referral in a timely manner we ask that you provide the following:

      Your Information
      SSN
      ID 
      Insurance Card
      Court Documents (If applicable) 
      Prior Treatment History (If applicable)     
    • Parent/Legal Guardian  
    • Disclosure

      Terms and Conditions for Parent &/or Legal Guardian
    • In order for us to process a referral for a minor or adult for whom you are the parent &/or legal guardian the following is required: 

      1. You must confirm that you are the parent &/or legal guardian and have the legal right to seek services

      2. You must confirm that the reason for seeking services is not for the purpose of having our providers testify in any current or upcoming custody cases. 

      3. You must confirm that you will disclose any previous or current changes related to the physical and/or legal custody of a minor client.

      Additionally you are required to provide the following information (if applicable) when making the referral: 

      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   

       

    • 3rd Party Disclosure 
    • Disclosure

      Terms and Conditions for 3rd Parties
    • In order to process referrals from third parties in a timely manner we ask the following: 

      1. Prior to making the referral you are required to notify and receive consent from the individual and/or their parent/legal guardian(s). 

      2. You are able to provide the following information (if applicable) when making the referral:  

      Adult Info. Minor info.
      Demographic Info.  Demographic Info. 
      Contact Info.  Guardian(s) contact Info. 
      Signed Authorization Form  Signed Authorization Form 
      Prior Treatment History Prior Treatment History 
    • School Disclosure 
    • Disclosure

      Terms and Conditions for School Staff
    • In order to process all in-school referrals in a timely manner we ask the following: 

      1. Prior to making the referral you are required to notify and/or receive the consent of the parent/legal guardian(s) for this student. 

      2. You are required to provide the following information when making the referral: 

      Student Information  Guardianship Information 
      Full Name Guardian(s) Full Name
      Student ID # Relationship to Student 
      Demographic Info.  Contact Info. 
    • DHHR/FTC Disclosure 
    • Disclosure

      Terms and Conditions for DHHR/FTC Referrals
    • In order to process DHHR or Family Treatment Court referrals in a timely manner we ask the following: 

      1. Prior to making the referral you are required to notify the participant.

      2. You are required to provide the following information when making the referral:  

      Participant Information 
      Demographic Info. 
      Contact Info. 
      Completed ROI  
      Any & All necessary Court/CPS/DHHR paper work 
    • Terms & Conditons 
  • Referral Source Information

    Referral Source Information

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  • Parent &/or Legal Guardian

    Referral Source
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  • Prospective Client Information

    Prospective Client Information

    • Client Demographic Information  
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    • Gender Breakdown  
    • A person who identifies as.....

      Agender :  Does not identify w/any particular gender or may have no gender. 

      Cisgender : Identifies with the sex they were assigned at birth (Female or Male) 

      Gender Fluid: Has no fixed gender. Shifting gender identity and presentation overtime.

      Transgender: Identify with a gender different then the one assigned at birth

      Although this list is not representative of all genders, we are all inclusive so if you identify with another gender please be sure to select "other" or "prefer not to say" in the Gender selection box. During the enrollment process we will reachout and at that time please feel free to inform us of how you identify. 

    • Address & Contact Information  
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  • Service Information

    Service Information

    • All Services 
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  • Insurance & Billing Information

    Insurance & Billing Information

    • Medicaid/MCO 
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    • Insurance Coverage Information  
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  • 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.
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  • I * 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.

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    • ASSIGNMENT OF REFERRAL  
    • 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. 

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