Complete the Referral Form below to the best of your ability. If you need assistance to complete the form or have further questions, please contact NDPHP at 701.751.5059 or

A referral may also be completed by mailing, faxing, or emailing a detailed letter, including the information from the referral form below, to NDPHP at:

Mail: 919 S. 7th St. Suite 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.