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HH Referral Form
Harmony Health, PLLC Therapeutic Services
3124 Milton Rd Suite 308
Charlotte, NC 28215
Tel: 704-469-1243
Fax: 704-469-1713
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Email
*
Your email
Date of Referral:
MM
/
DD
/
YYYY
Referral Source: As a referrer, HIPAA allows us to inform you of updates regarding mutual member until services are initiated. This supports coordinated care efforts. If you wish to have continued updates, the family member must have a signed consent on file for you.
*
Self
DSS/YFS
DJJ
Court
Agency
Primary Care
Law Enforcement
School
RWCI
Village HeartBeat
A.C.E
Pat's Place
Other:
Reason for referral [Please check all that apply]:
*
Mental Health Services [Individual, Family, Group]
Tobacco Treatment Services
Parenting Services
A Call To Men Male Youth Groups
Psychiatric Services with MindHeart Institute [currently 18 and over, limited ins accepted]
Required
Contact's Name/Agency/Organization:
*
Your answer
Contact's Phone Number:
*
Your answer
Contact's Direct Email:
*
Your answer
How do you prefer we contact you with any needs or questions?
*
Contact number listed above
Contact email listed above
Other:
Required
Family Member's Name:
If 18 or over, Please provide the young adult's name and contact info, not the caregivers'.
Please provide a
separate
form for EACH family member needing services.
*
Your answer
[If under 18]
Family Member's Legal Caregiver name:
Please note, if caregiver is not biological parents, please provide court documentation or advise family to provide during intake.
Your answer
[If under 18]
Does the child live with the Legal Caregiver?
Please note, if caregiver is not biological parents, please provide court documentation or advise family to provide during intake.
Yes
No
Clear selection
Family Member's /Legal Caregiver's Phone:
Your answer
Family Member's /Legal Caregiver's Email:
Your answer
Family Member's /Legal Caregiver's Address:
Your answer
Family Member's D.O.B:
*
Your answer
Family Member's AGE:
*
Your answer
Family Member's RACE:
*
Your answer
Family Member's Ethnicity:
*
Your answer
Family Member's Primary Language:
*
Your answer
Does the Family Member have a Disability:
*
Yes
No
How will it impact service needs?
Your answer
How will services be paid for:
*
Self Pay
Insurance
By Community Partner Contract [may require consent to release info]
3rd Party funding Source [requires consent to release info]
If 3rd party funding Source, Please list name and contact person's information. Please remember to request consent to release info:
Your answer
Medicaid/Insurance Information (n/a if none)
Please Provide Insurance agency and Policy Number:
*
Your answer
Triage Severity of need:
Please note, we are not a crisis agency and do not offer crisis services. We provide crisis counseling ONLY to current HH Family members in our care.
*
This referral is urgent (Intake will be sent within 48hrs)
This referral is routine (Intake will be sent within 5 days)
If urgent, please explain crisis need below:
Your answer
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