Safety Net Program Provider Referral
This form is for hospitals, law enforcement, and other agencies to refer clients to Dial Help's Safety Net Program. Clients will receive follow-up phone calls or texts from Dial Help, with the goal of helping them access professional treatment or counseling services, and supporting them in staying stable until they do.
READ THIS! CONSENT FROM YOUR CLIENT IS REQUIRED TO ENROLL THEM
Only refer people who have consented to receive Safety Net Program services. Do NOT enroll clients without telling them and obtaining at least a verbal consent.
You do not need to fill out this form for your client to access the crisis line. They can reach out 24/7 for support by calling 482-HELP, texting 906-35NEEDS, or chatting online at
To enroll yourself in the program, visit
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This form was created inside of Dial Help Inc.