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Nichols Center
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Crisis Response Douglas
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Submit Referral
REFERRALS
JOIN OUR PROGRAMS
Self Assessment & Referral Form
Please fill out the following form in order to participate in our groups or programs.
Name
Birthday
Phone
Email
County
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
Community Service
Trauma Support
Women's Wellness
Suicide Intervention Training
Veterans & First Responders
Mental Health Management
NAMI Mental Health Peer Services
Other Family Resources needed:
I would like to to volunteer.
I want to subscribe to the newsletter.
Submit
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