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Professional Intake Referral

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​Use this secure form to request individual therapy or refer to one of Alpine’s SUD and MH Intensive Outpatient Programs. Please note that our IOP services are only offered in the state of Colorado.

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Submitting this form does not guarantee admission, appointment availability, insurance coverage, or authorization. An Alpine’s team member will review the information and contact the appropriate person regarding availability and next steps.

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Do not use this form for emergencies. If someone is in immediate danger, call 911 or go to the nearest emergency department. Call or text 988 for crisis support.

Who is completing this form?
Preferred contact method
May Alpine's leave a voicemail?
What service are you requesting?
Birthday
Month
Day
Year
What state are you located in?
Interpreter or communication accommodations needed?
Are any of the following current or recent concerns present?

This form is not monitored continuously and submitting it does not initiate an emergency response. For an immediate safety concern, call 911 or go to the nearest emergency department. Call or text 988 for crisis support.

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