top of page

Privacy & Confidentiality Notice

H.O.P. Mental Health Services respects your privacy and is committed to protecting personal information. Information collected through this referral form is used solely for the purpose of responding to service inquiries, coordinating education, training, and community-based mental health support, and making appropriate referrals.

​

Please do not include protected health information (PHI) such as diagnoses, medical records, treatment history, Social Security numbers, or detailed clinical information on this form.

Service Referral & Inquiry Form

This form is for referrals and service inquiries only. It does not constitute emergency or crisis services. If you are in immediate danger, please call 911.

Referral Type
Reason for Referral
Urgency of Request
Immediate (within 1–3 days)
Moderate (within 1–2 weeks)
Routine / General Inquiry
Services Requested

Information Use & Disclosure Statement

Use of Information:

Information submitted may be reviewed by authorized H.O.P. Mental Health Services staff and, when necessary, shared only with trusted community partners for the purpose of coordinating requested services or referrals. Information will not be sold or shared for marketing purposes.


All information is maintained in a secure manner consistent with applicable privacy and confidentiality standards.

Consent & Acknowledgment

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Month
Day
Year
bottom of page