Professional Intake Referral

Colorado Only

Use this secure form to request individual therapy, refer an adolescent to Alpine’s Intensive Outpatient Program, or express interest in future young-adult IOP services.

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.

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?

Name of person completing this form

Organization or Agency

Email Address

Phone Number

Preferred contact method

May Alpine's leave a voicemail?

Best days and times to contact you

What service are you requesting?

Birthday

Month

Day

Year

Age

Parent/legal guardian's name, if under 18

Preferred language

Interpreter or communication accommodations needed?

Who has legal authority to consent to treatment?

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.