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 complete by emailing information to info@ndphp.org

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)

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