ON-LINE ADMISSIONS ASSISTANCE

Admissions Entrance to Harmony

At Harmony Foundation, we are committed to easing the client's transition into treatment. Our admission form makes available two ways to begin a confidential, no obligation dialog with an Admissions Professional.

The admission form allows the client, his or her family member, or professional referral provide Harmony Foundation with the information we will need to begin the admission process. Completing this form does not obligate treatment with Harmony Foundation. If you need immediate assistance, please call 866-686-7867(toll free), 970-586-4491 or 970-577-3164.

PLEASE SUBMIT ADMISSION FORM BELOW

COST OF TREATMENT AND PAYMENT OPTIONS

* Prospective Client's First Name
* Prospective Client's Last Name
* Prospective Client's Email
* Prospective Client's Home Phone (example 970-555-1212)
* Prospective Client's Cell Phone (example 970-555-1212)
* Prospective Client's Address
* Prospective Client's Address 2
* Prospective Client's City
* Prospective Client's State
* Prospective Client's Zip Code
Other country than United States? If so, please type in country name
* Prospective Client's Date of Birth (example 01/02/2003)
* Prospective Client's Gender
* How do you plan to pay for treatment?
* Guarantor's Full Name
* Guarantor's Relationship to Prospective Client
* Guarantor's Contact Phone Number (example 970-555-1212)
Employer
Insurance Company
Insurance Company telephone number for Benefits
Policy ID number
Group number
* Person Completing this form - First and Last Name
* Person Completing this form - Relationship to client
* Person Completing this form - Contact phone (example 970-555-1212)
Referred by (if applicable) Full Name/Agency
Referred by (if applicable) Relationship to Prospective Client
* Required Fields

"...the realities of the abuse problems are presented in a supportive, caring and non-judgmental fashion..."

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Call HARMONY FOUNDATION 1-866-6 TO STOP (686-7867)

"There ain't no cloud so thick that the sun ain't shinin' on t'other side."

ON-LINE ADMISSIONS ASSISTANCE