Referrals

Refer your yourself, family members, clients, patients, students to access services with AllHealth Network. After this form is submitted, we will attempt to contact the person being referred within 24 business hours.

If this is a mental health crisis, call 303-730-3303. Do not complete this form for a mental health crisis.

If you would like to speak to someone to make a referral by phone please call 303-730-8858 for assistance.

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.