Referral Form - Aurora Mental Health & Recovery

Referral Form

Please use the form below to refer someone for services with Aurora Mental Health & Recovery – including the Cultural Development & Wellness Center. You may use this form to refer another individual as either a partner agency or someone who knows the individual in another way. Please make sure they are aware you are completing the referral form and are comfortable with their information being provided.

NOTICE: If you do not receive an immediate confirmation of your submission on this page AND an email confirmation to the referring contact's email address within 1 hour, please submit your referral again or call the number for the program you are referring to.

AMHR Mental Health and/or Substance Use Referrals

Our care coordination staff will confirm that the referral was received and begin the outreach process. If you have a release of information that the client has completed, please email that to [email protected].

Any questions or concerns can also be directed to [email protected].

If you are interested in Mental Health and/or Substance Use services for yourself, please do NOT fill out this form. Instead, visit our Connect to Care (C2C) Clinic at 791 Chambers Rd. Aurora, CO 80011 or call us at (303) 617-2300.

Cultural Development & Wellness Center Referrals

Asian Pacific Clinic

For assistance with referrals to the Cultural Development & Wellness Center Asian Pacific Clinic, please call (720) 839-0162 or email [email protected].

Refugee & Immigrant Clinic

For assistance with referrals to the Cultural Development & Wellness Center Refugee & Immigrant Clinic, please email [email protected].

Victim Assistance

If you are in need of immediate assistance, please call our Victim Assistance Crisis Line at: (720) 394-7909 or call 911.

For more information about services or referrals, please contact [email protected]. All communication with the Victim Assistance program is confidential, privileged, and free of charge.

Victim Assistance - For Myself

To refer yourself to the Victim Assistance program, please fill out the form below. We will contact you within 1-3 business days. If you are referring yourself to the Victim Assistance program and you need help completing the form, please call (303) 923-2920.

Victim Assistance – For Someone Else & Hate Crime Reporting

To refer an individual or yourself to the Victim Assistance program, please fill out the referral form below, and we will do our best to respond within 24 hours if a crisis is indicated. However, we strongly suggest calling the crisis line at (720) 394-7909 if you or someone else needs immediate help. Other requests will have a response between 1 and 5 business days.

Referral Appointment Form

Referring To(Required)

Cultural Development & Wellness Center Program(Required)

Please Indicate Level of Urgency(Required)

If someone is in need of immediate help, please call our crisis line at (720) 394-7909!

Relationship to Referred Individual(Required)

Referring Agency (Only if Applicable)

Referring Contact Name(Required)

Referring Contact Phone(Required)

Referring Contact Email(Required)

Enter Email Confirm Email

Would you like us to contact you before contacting the client?(Required)

Yes

Would you like a follow up after we make contact with the client?(Required)

Yes

FIRST NAME of Referred Individual(Required)

LAST NAME of Referred Individual(Required)

GUARDIAN FIRST/LAST NAME of Referred Individual

DATE OF BIRTH of Referred Individual(Required)

PHONE # of Referred Individual(Required)

EMAIL of Referred Individual(Required)

Enter Email Confirm Email

ADDRESS of Referred Individual(Required)

Client Location (County)

Is the Referred Individual currently experiencing homelessness?(Required)

Primary Language(Required)

Interpreter Needed?(Required)

Insurance Type?(Required)

Insurance ID Number(Required)

Race/Ethnicity(Required)

Black or African American

African

White

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaska Native

Hispanic or Latinx

Other

Unknown or prefer not to answer

Race/Ethnicity (If "Other")

Sex Assigned at Birth(Required)

Gender(Required)

Gender (If "Other")

Pronouns

He/him

She/her

They/them

Other

Victimization (if other, please indicate below)

Human Trafficking (Sex & Labor)

Sex Trafficking

Labor Trafficking

Labor Exploitation

Domestic Violence

Elder Abuse

Physical Assault (not Domestic Violence)

Sexual Assault

Child Abuse

Identity Theft

Burglary

Robbery

Mass Violence

Stalking/Harassment

Other

Date of Incident

What kind of incident did you experience?

Avoidance/Shunning (e.g. deliberate avoidance of, distancing from, or social rejection of racial/ethnic group)

Verbal Harassment/Name Calling

Coughed At/Spat Upon

Physical Assault

Workplace Discrimination

Refusal of service at a business establishment (e.g. restaurants, shops)

Refusal of service in public transit or private transportation (e.g. rideshare services)

Vandalism/Graffiti

Online misconduct misconduct (e.g. racist messaging, harassing or disrespectful posts, creating an unsafe environment)

Other

Choose as many as you'd like.

Do you think specific parts of your identity were targeted in this incident?

RACE - Where I’m perceived to be from

ETHNICITY - My culture

GENDER - The gender I identify with or how I believe people see me

SEXUALITY - Who I am attracted to or who my attraction is perceived to be directed towards

LANGUAGE - I was not speaking English

RELIGION - What I believe in/where I worship

FOOD - What I was eating, purchasing

Other

Choose as many as you'd like.

Were there any kind of racist/hurtful slurs used?

In your words, what happened?

Please provide 2-3 sentences describing the incident.

In what city did the incident happen?

In what kind of location did the incident happen?

Did you happen to record/have images of what happened?

Please email any images/video to '[email protected]' with an incident date/city in file name.

Are there any links to news clips or social media posts?

Reason for Referral

Additional Information

Please share with us as much as you can about the client to limit the client's need to share their story multiple times.

Upload Attachments

Max. file size: 1 MB.

If you are experiencing a mental health crisis, please visit our Walk-in Crisis Clinic located at 2206 Victor Street in Aurora, 24/7/365.

Are you feeling overwhelmed and need to talk? Call us at 303.617.2300, 24/7/365.