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Admission

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. 

PLEASE SUBMIT ADMISSION FORM BELOW

COST OF TREATMENT AND PAYMENT OPTIONS
What to bring to Harmony and How to get there
 

* 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
 

* Would you like to be added to our email list for newsletters?

* Required Fields
 
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