REFERRALS

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 info@ndphp.org.

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

Email: info@ndphp.org

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)

CAPTCHA

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