Referrals

Are you looking to refer a patient to Happy Hearts?
To refer a patient, please choose one of the following options:
  1. Fill Out the Form Below – Complete and submit the referral form directly on this page (see below).
  2. Download and Submit the Form – Click here to download a copy of our Provider Referral Form. Once completed, you can upload it here or fax it to 855-470-4201.
Are you looking to refer a patient to Happy Hearts?
To refer a patient, please choose one of the following options:
1. Fill Out the Form Below – Complete and submit the referral form directly on this page (see below).
2. Download and Submit the Form – Click here to download a copy of our Provider Referral Form. Once completed, you can upload it here or fax it to 855-470-4201.

"*" 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.