Refer a client to Her Aria

Case managers, treatment centers, probation officers, and family members can use this form to start a referral. The form opens a pre-filled email to hello@heraria.com from your own email application — you press send, and we answer within one business day. You can also just call (909) 817-1507.

Your Information

Your Name *

Organization

Your Email *

Your Phone

I am a *

Client Information

Client Name *

Client Age

Client Email

Client Phone

Primary Substance

Length of Sobriety

On MAT?

What we need to know to assess a placement

Please leave out diagnoses, medication names and clinical records. This form travels by ordinary email. We only need enough to know whether the home is a fit.

Desired Move-in Date

Bed Preference

Funding Source

We are not contracted with any health plan or county yet, but we do accept third-party payment and can complete a W-9 or rental verification so a program can pay us directly. Tell us the source and we will work with it.

Additional Notes

How this form works. This sends straight to the person who runs the house. If our form is unreachable for any reason, your own email application opens with these details filled in instead — and if that happens you have to press send there. Either way you can always call (909) 817-1507 or email hello@heraria.com directly.

We answer within one business day

Rather not use the form?

Call (909) 817-1507 Email hello@heraria.com

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Nothing has been sent. Please call (909) 817-1507 or email hello@heraria.com with the details you entered above — your answers are still on this page. We answer within one business day.

Refer a client to Her Aria

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