Referrals

Are you looking to refer a patient to Happy Hearts? Click here to download a copy of our Provider Referral Form and upload it below or fill out the form online.

"*" indicates required fields

Referring Provider Information

Provider Type*

Parent / Child Information

MM slash DD slash YYYY
Autism Diagnosis

Insurance Information

Supporting Documentation

Untitled
Untitled
Drop files here or
Max. file size: 450 MB.
    Please upload a copy of the referral form for ABA therapy and the complete diagnosis report.

    Drop files here or
    Max. file size: 450 MB.