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To complete a referral for the NDPHP, please complete the form below to the best of your ability.
A referral may also be completed by sending a detailed letter, including the information below, to NDPHP.

919 S. 7th St. Ste 305
Bismarck, ND 58504

Fax: 701-751-7518

Contact Information for Person Being Referred

MM slash DD slash YYYY
Employer Address

Contact Information for Person Submitting Referral (N/A if Self-Referral)

Your name will be kept confidential.
Referrer Address

Up to 20% of Healthcare providers will be affected by a mental illness or substance use disorder during their lifetime.