Secure Services Inquiry and Referral Form—Colorado

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.

Name of person completing this form

Organization or agency

Relationship to prospective client

Email address:

Phone Number:

Best days and times to contact you

Prospective client’s legal name

Preferred name

Date of Birth

Age

Parent/legal guardian’s name, if under 18

Parent/Legal Guardian’s Phone Number

Parent/Legal Guardian’s Email Address

Parent/Legal Guardian’s Phone Number

Preferred language

Who has legal authority to consent to treatment?

Brief explanation, if applicable

Primary reason for seeking therapy

Please describe the primary behavioral health concerns or recent stressors prompting this referral.

Is the client currently receiving therapy?

Alpine’s Adolescent & Young Adult IOP cohorts are intended for ages 12–25 who may need more support than weekly outpatient therapy provides. Admission depends on clinical assessment, safety considerations, program capacity, service availability, and insurance or payment verification.

Are any of the following current or recent concerns present?

Suicidal ideation

Self-harm

Substance use creating an immediate medical or safety concern

Runaway risk

Aggression/Violence

Hallucinations or severe confusion

Suicide attempt or self-harm within the past 30 days

None

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.

Your information will be encrypted.

Secure Services Inquiry and Referral Form—Colorado

Alpine's Empowerment Agency-Counseling Services