For Providers

Please contact us with any questions about the completion or submission process for the following forms.

Click Here for information on Agreement to Cooperate requirements

Agreement to Cooperate form

10.63 Licensing Application

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

Homeless ID Project Application Form

Homeless ID Project Verification Form

Lab/Med Request Form

PATH Referral Form

Permanent Supportive Housing Referral

Respite Referral Form

School-Based Mental Health 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"