HAP Referral Form

Heartland Assistance Program Referral Form
West Des Moines: 515 331 0303 l Fax: 515 331 9086

Pella: 641 628 9599 l Fax: 641 621 1493
Name of Referring Organization
HAP Representative referring the Potential Client
Date of Referral

MonthDayYear
Date
Name of Client
Client Date of Birth

MonthDayYear
Date
Client 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 insurance, the organization is committed to funding the client's counseling:

PartiallyFully
The organization will pay for (# of sessions) sessions at the cost of ($ per session) per session.
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 HAP Representative of the Leadership of the Organization and the potential Client being referred to for counseling at Heartland.
Signature of HAP Representative

Clear
Signature Client or Guardian (if under 18)

Clear
Should be Empty:

Heartland Assistance Program Referral Form