Heart and Solutions Referral Form

  • Heart and Solutions Referral Form

  • In order to complete this form in its entirety, you will need the following information for the person seeking services: Social security number, insurance details and insurance subscriber information.

  • Upon completion of this form someone from Heart and Solutions will be in touch within 5 business days.

    If you experience a technical difficulty with this form, please contact us at help@heartandsolutions.net


  • Service Disclosure: Please be aware that our services and specific provider availability are not guaranteed. Providers operate on a first-come, first-served basis, and caseloads may reach capacity during the intake process. Additionally, unforeseeable circumstances may lead to unexpected unavailability of certain providers. We appreciate your understanding of these potential challenges.

  • CLIENT DEMOGRAPHICS

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Clients who are dependent adults or over 18 years of age: If you are sending bills to your parents and they are making payments on your account a release of information is required to be completed prior to the start of services. Please indicate to release “billing info” only unless you wish to give them access to all of your records. Please check one of the following options:

  • PARENT/LEGAL GUARDIAN

    (If the client is a MINOR) Legal guardian must sign consent for treatment and all releases.

  • GUARANTOR

    (If the client is a MINOR or if the guarantor is someone other than the adult client) The financially responsible party.
  •  - -
  • Format: (000) 000-0000.

  • Guardian 1

  • Format: (000) 000-0000.
  •  - -

  • Guardian 2

  • Format: (000) 000-0000.
  •  - -

  • EMERGENCY CONTACT

    (Contacted ONLY if there is a medical or mental health emergency.) Person to reach if a minor’s parent/guardian cannot be contacted.
  • Format: (000) 000-0000.

  • Other Information

  • INSURANCE

    Please be advised that while we can verify insurance eligibility,  and network status, at the time of the referral, we are unable to verify your specific plan benefits and out of pocket costs with your insurance carrier. It is your responsibility to verify your own benefits and out of pocket costs with your insurance carrier for the services being rendered. To do so, please call the number on the back of your insurance card prior to your first session.

  • (PRIMARY)

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  • (SECONDARY)

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  • Insurance Disclosure:

  • Please be advised that while we can verify insurance eligibility,  and network status, at the time of the referral, we are unable to verify your specific plan benefits and out of pocket costs with your insurance carrier. It is your responsibility to verify your own benefits and out of pocket costs with your insurance carrier for the services being rendered. To do so, please call the number on the back of your insurance card prior to your first session.

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