Referrals

Refer yourself, patients, students, clients, and family members to access services through the Assessment Center.

If this is an emergency, or mental health crisis, call (303) 730-3303 or 911. Do not complete this form.

If you would like to speak to someone to make a referral by phone please call (720) 696-7760 for assistance. After this form is submitted, we will attempt to contact the person being referred within 24 business hours.

To make a referral, please identify who you are:
Person Being Referred
First Name
Last Name
Date of Birth*
MM slash DD slash YYYY
Phone Number*
Email Address*
Is the person being referred aware of a referral being made on their behalf?*
- Yes
- No
Person Making Referral
Your Full Name*
Relationship to Referred Person
Your Phone Number
Your Email Address
Additional Contact Information
Who should we contact to schedule?*
Contact Phone Number*
Relationship to the person being referred?*
Parents Full Name*
Parents Phone Number*
Parents Secondary Phone Number*
Referring Institution Information
Institution Name*
Contact Name*
Job Title
Contact Email*
Contact Phone Number*
Contact Fax Number
Supervisors Name*
Supervisors Phone Number*
Supervisors Email Address*
Referring Agency Information
Agency Name*
Contact Name*
Job Title
Contact Email*
Contact Phone Number*
Contact Fax Number
Questions about Referral
Is the person being referred in Foster Care?*
- Yes
- No
- Unknown
Foster Parents Name*
Foster Parents Phone*
Is the client a registered sex offender or currently charged with a sex offense?*
- Yes
- No
- Unknown
Are the Decision Maker and the Contact Person to schedule the appointment the same?**
- Yes
- No
- Unknown
Name of the Legal Guardian or Medical Decision Maker
Phone Number of the Legal Guardian or Medical Decision Maker
Please choose the funding or insurance source:*
Reason for Referral
Referring for the following service:
- Mental Health Assessment with authorization to enroll into clinically appropriate services
- Second Substance Use Assessment with authorization to enroll into clinically appropriate services
- Evaluation only with no authorization to enroll into clinically appropriate services
Please state the reason for this referral:
Request Progress Reports
Please select the information requested to be provided back to you:
- Evaluation and treatment recommendations
- Monthly progress reports
- Notification of missed appointments
- Notification of lack of engagement
- Treatment Plan
Documentation Upload
You can use this area to include any documentation to provide more information about your referral. AllHealth Network must receive the following documents with (**) next to them prior to scheduling and appointment for individuals on probation or parole.
Please check the items you are uploading:
- Assessment or Case Summary **
- Background / Collateral Information **
- Consent to Treat
- Court Orders **
- Family Meeting / Faces Notes (DHS Only) **
- Family Treatment Plan
- Police Reports
- Probation/Parole Conditions or Stipulations **
- Other Document
Upload the client documents:
Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, txt, gif, xls, xlsx, ppt, pptx, Max. file size: 30 MB, Max. files: 10.
Document consent:*
I understand that the required documents denoted with asterisks (**) are needed before an appointment can be setup with the client.