Formulario para recibir servicios en La Cocina

1

Hello and thank you for reaching out to us. In order to serve you best, La Cocina now has a new referral form. Please click on THIS LINK to be redirected there now.

We look forward to connecting with you soon!

Hola y gracias por comunicarse con nosotros. Para poder servirle mejor, La Cocina ahora tiene un nuevo formulario de referencia. Por favor, haga clic en ESTE ENLACE para ser redirigido allí ahora.

¡Esperamos conectarnos con usted pronto!

2

Name of person being referred (required)* This field is required.If you are a parent or adult referring a child, please put their name here.

Primer Nombre

Apellido

3

This referral is for a person who is a:

Young child (age birth to 5 years old)

Youth (age 6 to 12 years old)

Teenager (age 13 to 17 years old)

Adult (18 years and older)

4

Date of birth of person being referred.* This field is required.

5

Phone number (required)* This field is required.

Código de área

Número de teléfono

6

Can we text this number?* This field is required.

YESNO

7

Can we leave a voicemail at this number?* This field is required.

YESNO

8

Preferred language for communication.* This field is required.

Spanish

English

Other

9

This referral is for the following services:Choose all that apply.

Individual therapy for myself

Individual therapy for a family member or someone I know

Family or couple therapy for myself

Family or couple therapy for someone I know

Neurodevelopmental or Psychological Assessment (This is an evaluation to better understand a person's development, behavior, and/or mental health)

Group therapy support

I am pregnant and looking for support during my pregnancy and/or birth

Something else...please connect with me to learn more.

I am not exactly sure...someone suggested that I contact you

10

Are you making a referral on behalf of an Eagle County individual or family?* This field is required.

YESNO

11

Do you or the person you are referring have Medicaid?

YESNO

12

County of residence for person being referred:* This field is required.

13

Name of person completing this form.* This field is required.

Primer Nombre

Apellido

14

Your phone number * This field is required.

Código de área

Número de teléfono

15

If you are referring someone else, does this person know you are referring them?

YESNO

16

Please provide a brief description of the reason for referral.* This field is required.

17

Does this family have an open case with DHS?* This field is required.

YESNO

18

How many sessions has this client been approved for?* This field is required.

19

Please upload a copy of the Service Authorization Form here.* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

20

Please upload a copy of the signed Release of Information here.* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB