For Providers:

Please complete and submit the two documents below for the agreement to cooperate process:

Agreement to cooperate census form

Agreement to Cooperate form

Please submit all requested information to:

Jamie Miller- Jmiller@harfordmentalhealth.org

For Substance Use only programs please submit documents to:

Shawn Martin- shawn.martin@maryland.gov

Provider Forms

Application for Residential Rehabilitation Services, PDF (RRP)

432 MDH Budget Form

Case Management Referral Form

Child & Adolescent Care Coordination Referral Form (CCO)

Critical Incident Form

Consumer Support Funds Application Form

Community SOAR Referral

Homeless ID Project Application Form

Lab/Med Request Form

PATH Referral Form

Permanent Supportive Housing Referral

TCM Plus Referral

Provider Resources (Accreditation/Licensure/MDH/BHA/COMAR/Optum/NPI)

Thinking about becoming a behavioral health provider in Harford County? Click below to learn more:

More Information

“Office on Mental Health – Creating space for recovery, healing, and hope for all in Harford”