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Nichols Center
Living Plant Shop
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Referral
Submit Referral
REFERRALS
JOIN OUR PROGRAMS
Self Assessment & Referral Form
Please fill out the following form in order to participate in our groups.
First name
Birthday
Phone
Email
Address
Do you have a mental health diagnosis/concern?
No
Mental Health
Substance Use Disorder
Dual Diagnosis
Suicide Attempt
Trauma/PTSD
Grief and Loss
Do you have a family member with a mental health diagnosis/concern?
No
Mental Health
Substance Use Disorder
Dual Diagnosis
Suicide Attempt
Trauma/PTSD
Grief and Loss
Have you been referred by a provider?
No
Therapist/Phychiatrist
Accountability Court
Court Services/Court Ordered
Community Program/Partner
Groups or Classes interested in attending:
Art Journaling
Addiction/Recovery Counseling
Anger Management
Community Service
Mental Health Management
NAMI Mental Health Peer Services
Suicide Intervention Training
Trauma Support
Veterans & First Responders
Volunteer Opportunities
Women's Wellness
Other Family Resources needed:
Submit
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