Refer a Patient

If you have a patient who is struggling with Mental Health or Substance Use and is in need of additional or continuing care, please fill out one of the forms below. If you wish to continue treating a referral patient as they go through the Aspire365 program, arrangements can be made. For additional information, please contact us at (385) 352-9696.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Upon completion of this form, an admissions team member will soon be in touch.

Referring Agent*

Type of Referral*

Medical Records/Discharge Paperwork

Max. file size: 64 MB.

Client Name*

Date of Birth*

Phone*

Email*

What is your preferred mode of communication?*

Text

Call

State of Residence*

Zip Code*

Insurance Provider*

Member/Subscriber ID*

Group Number*

Insurance Phone*

Do you have secondary insurance?

Yes

Secondary Insurance Provider*

Secondary Insurance: Member/Subscriber ID*

Secondary Insurance: Group Number*

Secondary Insurance Phone*

Requested Service(s)*

Mental Health Program

Substance Use Program

Mental Health Checkup

DBT Art Therapy Program (For ages 13 – 17 only)

Is Detox Needed?

Has the Individual Received Care Before?

Message*

How did you hear about Aspire365?*

If Other, please describe.*