If you or someone you know is experiencing a mental health crisis and needs immediate assistance, please call the Colorado crisis hotline at 844-493-TALK (8255). Or Text: TALK to 38255.

Current Client? Check box if "Yes".

First Name *

Last Name *

Date of Birth *

Phone *

Email *

Insurance *

Best time of day to call? * Early Morning Late Morning Mid-day Early Afternoon Late Afternoon Any

Are you homeless? Check box if "Yes". * Yes No Unknown

What brings you in? (check only those that apply) * Addiction ServicesCounseling ServicesPsychiatric ServicesOtherCrisis Services (If you are in Crisis, please call 719-635-7000 or visit our crisis walk in center at 115 S Parkside Dr.)

Additional notes, special needs/requests, gender preference of provider, etc

How did you hear about us? * Facebook Twitter LinkedIn Google Search Word of Mouth Previous Client Friend/Relative Mailer Story TV Newspaper Ad Peak Vista Physician/Professional Referral RCCO Value Care Yellow Pages Web Site (other) Other Mobile Radio News Web Site (Diversus Health)

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Thank you for contacting Diversus Health. We will follow up with you as quickly as possible to ensure your needs are met. If this is after normal business hours we may not contact you until the next business day.

If you or someone you know is experiencing a mental health crisis and needs immediate assistance, please call the Colorado crisis hotline at 844-493-TALK (8255). Or Text: TALK to 38255.