Professional Referral Form

Use this form if you are referring a client, patient, or participant to Helping Hands Project Organization for support or behavioral health services.

Our intake team reviews professional referrals daily. After submission, you’ll receive an email confirmation, and our team will contact you or the client within 2–3 business days.

Before You Begin

- Please ensure the client has given consent to share their information.
- Attach any supporting documentation that may assist our intake team.
- If the client is in crisis, call or text 988 for immediate help.

HHPO Professional Referral Form

HHPO Professional Referral Form

Referring Agency Information

Please complete this form if you’re referring a client to Helping Hands Project Organization as part of your professional role.

Client Information

Name of client being referred
Name of client being referred
First Name
Last Name
Client Address
Client Address
City
State/Province
Zip/Postal
Interpreter needed?
ProviderOne ID# also referred to as State, Member or Client ID#. The ProviderOne number is always a nine-digit number starting with 10 or 20 and ending in WA.
Address
Address
City
State/Province
Zip/Postal
Country

Reason for Referral

Currently taking prescribed medications?
Requested Services

Safety and Legal Information

Any concerns for client’s safety or risk of harm?
Are services court-ordered?
Is the client currently connected to another agency for services?
Has your client ever been arrested, charged, or convicted of:

Consent & Acknowledgment

By submitting this referral, you confirm that the client has given verbal or written consent to share their information with Helping Hands Project Organization for the purpose of service connection.

Consent to Contact