Hawaii Mental Health Pediatric Access Line (MPAL)

HI-MPAL Consultation Intake Form
For registered providers, please submit this HIPAA‑compliant form to tell us about your inquiry. Once you’ve submitted the form, a HI‑MPAL representative will contact you at the scheduled time and date you selected.
Referring Provider Information
Referring Provider Name

First NameLast Name
Name of referring clinic, if applicable
Practice Phone Number

Country CodeArea CodePhone Number
Practice Fax Number

Country CodeArea CodeFax Number
Referring PCP call back number

Country CodeArea CodePhone Number
Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Guardian Name

First NameLast Name
Guardian Phone Number

Country CodeArea CodePhone Number
Guardian Email
Race/Ethnicity (Select all that apply)
If other race/ethnicity, please specify
Sex assigned at birth
If other sex, please specify
Insurance Type
Primary Insurance
Secondary Insurance
Referral
Reason(s) for Consult
If other, please specify
Preferred call back time
Best time to call back (M-F business day, 8am to 4:30pm HST):

Warmline Operation Times: Pacific Basin Time Conversions

HI-MPAL Consultation Intake Form