Relationship to individual being referred Parent/Guardian Outpatient Provider (select agency below) Inpatient Provider (select agency below) Healthcare Provider (select agency below) Other
Referring Healthcare Agency (only if applicable) Centura Health Matthews Vu Optum Peak Vista Community Health Centers SET of Colorado Springs UCHealth Other
Referring Outpatient Agency (only if applicable) Achieve While Recovery Beverly Hawpe and Associates Bright Futures Psychiatry Bristlecone Family Counseling Catholic Charities Clear Skies Psychological Services, Inc. Colorado Psychiatric Services EMDR Center of the Pikes Peak Region, LLC Family Care Center Family Resource Network & Kaleidoscope Counseling Fulfillment Counseling Jeri Sutton-Shores, LPC Judith Gainer, LPC Lionheart Psychotherapy, PLLC Mayfield Counseling Meaningful Connections Therapy Mind Renewal Behavioral Health Services Mindful Springs Counseling, LLC Mt. Carmel Veterans Service Center Peak Neuropsychology & Brain Rehabilitation Perceptions Counseling Services Restoring Lives Project River of Life Counseling Roots to Ground Counseling Sam Jolman, MA LPC Counseling Serenity Psychotherapy, LLC Sharon Abeyta, LPC, LLC Stages of Change Psychotherapy The Bohemian Sanctuary The Family Center The Independence Center Teresa Guthmiller, LPC Counseling Services Thriveworks Counseling True Living Viewpoints Psychotherapy Other
Referring Inpatient Agency (only if applicable) Cedar Springs Hospital Colorado Mental Health Institute at Pueblo Colorado Mental Health Institute at Ft. Logan Denver Springs Highlands Behavioral Health Jefferson Hills Peak View Behavioral Health Other
If Inpatient, what is the projected discharge date?
Referrering Contact Name
Referring Contact Phone
Referring Contact Email
FIRST NAME of individual being referred
LAST NAME of individual being referred
DATE OF BIRTH of individual being referred
PHONE of Individual being referred
EMAIL of Individual being referred
INSURANCE of individual being referred
Is the individual being referred homeless? Yes No Unknown
Best time to call? Early Morning Late Morning Mid-day Early Afternoon Late Afternoon Any
Services Needed? (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.
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