Contact

Book Appointment

Contact

Book Appointment

Looking to Refer a Patient?

If you’re a provider interested in referring a patient to Haelen Mental Health, please complete the form below. Our team will review your referral and follow up with the next steps.

Looking to Refer a Patient?

If you’re a provider interested in referring a patient to Haelen Mental Health, please complete the form below. Our team will review your referral and follow up with the next steps.

Looking to Refer a Patient?

If you’re a provider interested in referring a patient to Haelen Mental Health, please complete the form below. Our team will review your referral and follow up with the next steps.

Your Name (First and Last)

Your Name (First and Last)

Your Name (First and Last)

Your Organization or Practice Name

Your Organization or Practice Name

Your Organization or Practice Name

Your Email

Your Email

Your Email

Your Phone

Your Phone

Your Phone

Has the client provided consent to share information with us and are they aware of this referral (Y/N)? *Please Note: Consent will be required to proceed*

Has the client provided consent to share information with us and are they aware of this referral (Y/N)? *Please Note: Consent will be required to proceed*

Has the client provided consent to share information with us and are they aware of this referral (Y/N)? *Please Note: Consent will be required to proceed*

Client Name (First and Last) and Pronouns

Client Name (First and Last) and Pronouns

Client Name (First and Last) and Pronouns

Client Phone Number

Client Phone Number

Client Phone Number

Client Email

Client Email

Client Email

Primary reason for referral (i.e. brief description of presenting concerns)

Primary reason for referral (i.e. brief description of presenting concerns)

Primary reason for referral (i.e. brief description of presenting concerns)

What services are being sought? (ex: Therapy, Medication Management, EMDR, Spravato, etc.)

What services are being sought? (ex: Therapy, Medication Management, EMDR, Spravato, etc.)

What services are being sought? (ex: Therapy, Medication Management, EMDR, Spravato, etc.)

Insurance Information (If known, or write "unknown")

Insurance Information (If known, or write “unknown”)

Insurance Information (If known, or write “unknown”)

Are there any additional notes or special considerations?

Are there any additional notes or special considerations?

Are there any additional notes or special considerations?

How did you hear about us?

How did you hear about us?

How did you hear about us?

Please contact our office at 720-469-2845 with any questions. Release of Records forms may be faxed to our office at 720-222-5729.

Please contact our office at 720-469-2845 with any questions. Release of Records forms may be faxed to our office at 720-222-5729.

Please contact our office at 720-469-2845 with any questions. Release of Records forms may be faxed to our office at 720-222-5729.

HAELEN

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connect@haelenmentalhealth.com

Phone: (720) 469-2845

Fax: 720-222-5729

Services

Psychiatric Evaluation

Individual Counseling

Medication Management

Company

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