Interested in Partnering with Us? We welcome the chance to include you in our local professional referral network. By completing the form below, you’ll be contacted about the opportunity to be included in our professional referral database. The professional referral database will allow our staff to refer individuals to you and your organization in the Houston area to aid them in their mental health journey. Someone from our team will follow up with all requests as soon as possible. Information NeededAgency/Practice Name:*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*What is your title/license?* Licensed Social Worker Licensed Professional Counselor Licensed Chemical Dependency Counselor Licensed Psychologist Case Manager Outreach Coordinator Other What is your title/license? Other:*Please list practice specializations (if any):*What service is provided?* Assessment & Testing CBT-Cognitive Behavioral Therapy DBT- Dialetical Behavorial Therapy Emergency Services (Crisis Centers) Inpatient Mental Health Outpatient Mental Health Psychiatry Substance Use Support Groups Supportive Housing Transportation Other What service is provided? Other:*Population served?* Children Only Adults Only Children & Adults Cost of Services:*Is sliding scale offered?* Yes No What type of insurance is accepted?* Blue Cross Blue Shield (HMO/PPO) Aetna (HMO/PPO) Cigna (HMO/PPO) Medicare Medicaid Amerigroup (HMO/PPO) United Health Care (HMO/PPO) Humana (HMO/PPO) Other NONE What type of insurance is accepted? Other:*Is your organization inclusive of the faith/religious needs of a client?* Yes No Please list all languages services are provided in:*Please Note: A HHCI staff member will contact you to review your recorded responses. HHCI will then determine if your organization will be included in our referral network. Thank you!
