Refer a patient

Important Disclaimer

This form is monitored Monday-Friday, 9:00 AM-5:00 PM and is not monitored after hours. We'll contact you within 48 hours for non-emergency submissions.

If you are experiencing a behavioral health emergency, please call 988, text 988, or use the live chat at 988colorado.com to connect with the Colorado Mental Health Crisis Line.

Your Information

What is your organization name?

What is your name?

What is your email address?

What is your phone number?

Preferred contact method

EmailPhone

Client Information

Client Name

Client Phone

Client Email

Client Zip Code

Client County

Insurance Information

Providing insurance information is not required but if your client has insurance, it will help us plan for their care. Does your client have health insurance?

YesNoDon't knowPrefer not to provide this information at this time

Please identify your current concerns or problems that are motivating you to seek services.

Self harming

Suicide attempts

Aggression towards others

Intoxication

Putting self or others at risk

Are you referring for a substance use disorder?

YesNo

Desired Services

Which service or services are you referring the client for?

Family Therapy

Individual Therapy

Intensive Outpatient Group Therapy (IOP)

Medication Management

Case Management

Peer Support

Assertive Community Treatment (ACT)

Crisis Services

Other (please specify)

Release of Information

Has the individual or family signed a release of information for Paragon?

YesNo

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