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. Whether you are referring an individual as a partner agency, or know the individual in another way, this form can be used. Before completing the form, please talk with the person about the referral, ensuring they are aware you are completing the referral form and are comfortable with their information being provided.

AMHR Mental Health and/or Substance Use Referrals

Our care coordination staff will confirm that the referral was received and then begin the outreach process. If you do have a release of information that the client has completed, please email that to CareCoordination@AuroraMHR.org.

Any questions or concerns can also be directed to CareCoordination@AuroraMHR.org.

For individuals who would like to refer themselves for Mental Health and/or Substance Use services, 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 Refugee & Immigrant Clinic Referrals

For assistance with referrals to the Cultural Development & Wellness Center Refugee & Immigrant Clinic, please email CRWCReferrals@AuroraMHR.org.

Cultural Development & Wellness Center Asian Pacific Clinic (Formerly APDC) Referrals

Behavioral Health Services at Asian Pacific Clinic

For assistance with referrals to the Cultural Development & Wellness Center Asian Pacific Clinic, please call (720) 839-0162 or email ClinicReferrals@AuroraMHR.org.

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 Victims@AuroraMHR.org. All communication with the Victim Assistance program is confidential, privileged, and free of charge.

Victim Assistance Self-Referral

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 Hate Crime Reporting

To refer an individual or yourself to the Victim Assistance Department, please fill out the referral form below and we will do our best to respond within 24 hours if crisis is indicated or up to 5 business days for other requests.

Referral Appointment Form

This form will allow you to refer an individual to AMHR Mental Health or Substance Use services and the Cultural Development & Wellness Center services. If you would like to refer yourself to AMHR Mental Health or Substance Use services, please visit our walk-in clinic or call (303) 617-2300 instead of filling out this form.

Referring To(Required)

Cultural Development & Wellness Center Asian Pacific Clinic (Formerly APDC) Program(Required)

Please Indicate Level of Urgency(Required)

Relationship to Referred Individual

Referring Agency (Only if Applicable)

Referring Contact Name(Required)

Referring Contact Phone(Required)

Referring Contact 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

PHONE # of Referred Individual(Required)

EMAIL of Referred Individual

ADDRESS of Referred Individual

Client Location (County)

Is the Referred Individual Homeless?

Primary Language

Interpreter Needed?

Date of Incident

Insurance Type?

Insurance ID Number

Race/Ethnicity

Black or African American

White

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaska Native

Hispanic or Latinx

Mixed Race

Other

Unknown or prefer not to answer

Sex Assigned at Birth

Gender

Victimization (if other, please indicate below)(Required)

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 'infocoredei@gmail.com' 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: 20 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.