Willow Collective QBHA Services Referral Form
Complete to refer a client or yourself for QBHA support services through 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

As a referred agency for services, the agency is responsible for performing duties and functions with respect to juvenile delinquency or dependency and neglect cases or other provisions of Title 19 of Colorado Revised Statutes; and may receive protected information pursuant to C.R.S. 19-1-303. The referred agency shall comply with all confidentiality obligations required by law.

After receiving this form, a member of our team will contact you/the client within 1-2 weeks. Please note that requesting a service does not guarantee you will receive it.  

**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 *
Client date of birth  *
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? *
Is client already receiving support from the Willow Collective through individual therapy, group therapy, or assessments? *
Client insurance *
When possible, we bill Medicaid insurance for QBHA services in order to support the financial sustainability of QBHA programing*. If you are self-referring and currently insured by Medicaid, would you feel comfortable allowing us to bill your insurance? 
*Please note that if you don't have Medicaid insurance, or if you prefer that we don't bill your Medicaid insurance, we will still provide support through alternative means of funding.
 *
Medicaid billing requires a mental health diagnosis. If you responded "Yes" to the question above and have received a diagnosis from a mental health provider that you feel comfortable sharing, please let us know in the text box below. However, if you haven't received a diagnosis or prefer not to share one, please disregard this question.
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) *
Reason for referral. Please provide sufficient detail for us to match to the appropriate QBHA support specialist: *
Are you involved with Larimer County DHS/child protection? *
Any other relevant information? (Please include any potential barriers to support)
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