REFERRALS

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

Name(Required)

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone(Required)

Profession(Required)

Birth Date

Licensing Number

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer Phone

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

Referrer Name(Required)

Your name will be kept confidential.

Referrer Address

Street Address Address Line 2 City State ZIP Code

Referrer Phone

Referrer Email(Required)

Referrer Facility

Referrer Relationship(Required)

Summary Of Concerns(Required)

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