Refer a Patient

Call our 24-hour referral hotline at 818-925-1451 or email info@harborcares.org and we’ll be happy to answer any questions and make sure they are a right fit. We also offer in-person assessments at your facility.

To get the process started:

Complete the Online Referral Form below.
Be ready to email us some pertinent patient information, including:

H & P notes
SW evaluations
PT notes
COVID test (within 24 hours)

Psych notes
Lab orders
Current medications

Email referrals to info@harborcares.org
Fax referrals to (818) 350-4105

Referral Form

Referring Organization Name(Required)

Paying Hospital/Insurance Company

Referral Contact Name

First Name Last Name

Title

Date

Submitter's Phone

Phone Extension

Fax Number

Patient Information

Patient Name(Required)

First Name Last Name

Date of Birth

Gender

Male

Female

Other

Primary Language

MRN Number

Patient Tier Level

Select Level

Medical Reason for Admission(Required)

Date

Est. Length of stay at Harbor Cares

Additional Notes

Is the patient currently medically and psychiatrically stable?

Is the patient in isolation for any communicable diseases?

File

Max. file size: 50 MB.

Approved

I affirm that the above information is accurate to the best of my knowledge.

Comments

This field is for validation purposes and should be left unchanged.

Refer a Patient

To get the process started:

Referral Form

Patient Information

Approved

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