Halcyon

New Client Implementation Form

Please complete the form below to notify CuraLinc Healthcare of a new Halcyon Behavioral client. Your CuraLinc Client Relationship Manager will send a confirmation of receipt within two business days.

Client Name

Program Effective Date

YYYY

Number of Employees

Halcyon Contact Name

First Name

Last Name

Halcyon Contact Email Address

Halcyon Contact Phone Number

(###)

###

####

Client Contact Name

First Name

Last Name

Client Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Contact Email Address

Client Contact Phone Number

(###)

###

####

Broker/Consultant Information

(if applicable)

Program

(choose one)

Halcyon EAP Plan Design

(choose one)

Halcyon EAP Website Username

Utilization Review (UR) Vendor

Does the company have a UR vendor? If so, who is the provider?

MHSA Network

Does the company provide mental health and substance abuse (MHSA) benefits? If so, what is the company's MHSA network(s)?

Additional Information

(if applicable)