Willow Collective Referral Form
Complete to refer a client or yourself for services from a provider with The Willow Collective.
*Note that our group accepts and manages referrals for pregnant or postpartum individuals and for families of children ages 0-6. For children older than age 6, CAYAC can help you find a provider: https://www.healthdistrict.org/cayac

After receiving this form, our referral manager will contact you/the client within 1-2 weeks. Please note that requesting a service does not guarantee you will receive it. The referral manager will talk with you about what services are available and what is most likely to meet your family's needs.  

**Do not refer clients for emergency services; if emergency help is needed, call 911 or contact Colorado Crisis Services: 1-844-493-8255
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Your name (referral source) *
Your (referring party) phone number and/or email: *
Your relationship to client / agency / organization *
Client name (*for Circle of Security & Nurturing Connections NoCo, this is the adult participant) *
Client date of birth (**note that we serve adults in the perinatal period and children ages 0-6) *
Client/parent phone number (please specify whose phone number) *
Is it okay to leave a voicemail or text at this number? *
Client/parent email address: *
Client primary language(s).  NOTE: *At this time, we have limited availability to serve Spanish speaking clients
Does client know you are making a referral? *
If client is a child, who currently has the rights to consent to mental health treatment? 
Client insurance *
Details on insurance (private insurance company and ID #): *
Please list names and ages of client's family members (e.g., if adult client: spouse/partner, children; if child client: parents, siblings) *
Our referral manager will call clients to identify needs and match to appropriate services. All of our 8-week groups can accept referrals at any time, and we will let the client know when a slot is available. 

Which of the following services may be a good fit (select as many as apply)?
ONLY if you are referring to Nurturing Connections NoCo, has the client been pre-screened for eligibility? (If you are not sure, select "no")
Clear selection
Reason for referral. Please provide sufficient detail for us to match to the appropriate provider: *
Any other relevant information? (Please include any potential barriers to care)
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