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Agency Referral Form

This form is for Agency staff members use only.  

Heritage Health for Women (formerly Heritage Pregnancy and Family Health Center) Referral Form 

All agency referrals or requests for services must be made through our main office at 667-215-0143 or using the form below returned either via our secure HIPAA compliant fax or email included on the form.

Heritage HFW does not provide licensed therapists or licensed counselors.  We do not diagnose or treat medical or mental health conditions but can be an adjunct to educational needs presented by our professional lay staff.

Please DO NOT SEND REFERRALS TO ANY STAFF PERSONAL EMAIL as personal laptop use may not be encrypted and may violate the privacy of your client or where personal information or communications may be improperly stored. 

Please click the AGENCY REFERRAL FORM button to the right to access the PDF file needed. 

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