Submit a Referral — The Hope and Healing Foundation Inc.

For Licensed Providers · Partner With Us

Submit a Client Referral

Partner with us to ensure your clients receive uninterrupted mental health care — regardless of their financial situation. Simple, secure, and provider-friendly.

Start Referral Client Application

Why Partner With Us

Benefits of Referring Your Clients

Our program is designed to complement your clinical work — reducing financial drop-offs and supporting client retention without adding burden to your practice.

Improve Retention

Reduce session cancellations and treatment drop-offs caused by out-of-pocket costs. Keep clients engaged in their care.

Simple Process

Our referral form is straightforward and takes under 10 minutes. No lengthy paperwork or administrative burden on your end.

Direct Payment to You

All assistance funds are paid directly to your practice — never to the client — ensuring full compliance and transparency.

Confidential & Secure

All client information shared through this referral is handled with strict confidentiality and HIPAA-aligned practices.

Expand Access to Care

Demonstrate your commitment to equitable, accessible mental health care for clients from all financial backgrounds.

Community Impact

Join a growing network of providers working with HHF to reduce financial barriers to mental health treatment statewide.

Who Can Refer

We Partner With Licensed Providers

Eligible Provider Types

Licensed Mental Health Counselors (LMHC)
Licensed Clinical Social Workers (LCSW)
Psychologists (PhD / PsyD)
Licensed Marriage & Family Therapists (LMFT)
Psychiatrists (MD / DO)
Group practices and outpatient mental health clinics
Community mental health organizations
Telehealth providers

Eligible Client Criteria

Has active health insurance with mental health benefits
Responsible for copayments or coinsurance per session
Experiencing financial hardship that affects care access
Currently receiving or preparing to begin outpatient care
Has consented to this referral and to direct provider payment

Provider Referral Form

Submit a Client for Copay Assistance

Complete this form on behalf of an eligible client. All information is kept strictly confidential and used solely for eligibility review.

Your Provider Information

Provider First Name *

Provider Last Name *

License Type *

License / NPI Number *

Practice / Organization *

Practice State *

Provider Email *

Provider Phone *

Service Delivery Method

Client Information

Only share information your client has consented to disclose. This data is used solely for eligibility review and program administration.

Client First Name *

Client Last Name *

Client Date of Birth *

Client Phone or Email *

Insurance & Copay Details

Client Insurance Provider *

Member / Policy ID

Copay / Coinsurance Per Session *

Estimated Sessions Per Month

Clinical Context & Need

Reason for referral *

Duration of treatment

Risk of discontinuation without assistance

Consent & Acknowledgment

I confirm that my client has provided informed consent for this referral and for direct payment to be made to my practice on their behalf.

I certify that the information provided is accurate and that my client meets the general eligibility criteria for this program.

I understand that submission does not guarantee approval. Eligibility is subject to review and available program funding.

I agree to cooperate with The Hope and Healing Foundation team for any follow-up needed to process this referral.

Referrals are reviewed within 5–7 business days. You'll be contacted at the email provided. Questions? Call (561) 779-0748.

Questions?