HMH Referral Form

Harmony Mental Health Inc.

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

MonthDayYear
Is this referral for a Minor or Adult?*

MinorAdult
Referral Source *
Access Code
Pre-assigned Access code. HMH Employee Only
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

Self
Disclosure

Terms and Conditions for Self Referrals

Parent/Legal Guardian
Disclosure

Terms and Conditions for Parent &/or Legal Guardian

3rd Party Disclosure
Disclosure

Terms and Conditions for 3rd Parties

Terms & Conditons

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.

Prospective Client Information

Client Demographic Information
SSN#*
Client Social Security Number
Marital Status
First Name *
Middle
Last Name *
Preferred or Alternative Name
Prefer to be called?
Preferred Pronouns
DOB*

MonthDayYear
Age*
Race *
Sex Assigned at Birth *
Gender *

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
County of Residence *
Homeless?

Yes
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please select at least two preferred methods of contact. *

CallTextEmail
Are we permitted to leave a voicemail?*

YesNo
Client or Guardian email *
example@example.com
Client or Guardian Main Number*
Best number to reach you
Alternative Number
Alternative number
Why we ask for two preferred methods of contact?

At this time we do not have the ability to contact referrals via text message. Therefore to to confirm the information provided in this referral and to schedule an intake, we will attempt confirmation via a phone call . Thus we ask for permission to leave a voicemail if our initial attempt to call fails.

Once a referral is received it undergos a verification review to confirm receipt of all documentation that is required for processing, if any documentaiton is missing we will attempt notification via email followed by a phone call.

Why we have "text" as an option?

We offer the "text" option, so that once a referred individual becomes established as a Harmony Mental Health, Inc. client, we can set them up in our EHR system to receive appointment text message reminders.

Insurance & Billing Information
What resources are available to pay for services?*

InsuranceDHHR: Requires Special Billing LetterMedicaid/MCOSelf-PayOther
Manage Care Organization (MCO)
Medicaid
Medicaid #
THP number starts with an H
Insurance Company
These are the insurances we can bill.
Insured Name *

First NameLast Name
Insured DOB*
Insured SSN# *
Group # *
Policy # *
Provider Customer Service Phone #*
Provider # is located on the back of the insurance card.