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Nichols Center
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Referral
REFERRALS
JOIN OUR PROGRAMS
Referral Form
Please fill out the following form in order to participate in our groups or programs.
First Name (Client)
Last Name (Client)
Parent Name (if under 18)
Referral Source Name
Email
Referral Source
No
Therapist/Psychiatrist
Accountability Court
Court Services/Court Ordered
Community Program/Partner
School Counselor
Phone
County
Birthday
Do you have a mental health diagnosis/concern?
No
Mental Health
Substance Use Disorder
Dual Diagnosis
Suicide Attempt
Trauma/PTSD
Grief and Loss
Mental Health Services
Mental Health
Substance Use Disorder
Dual Diagnosis
Suicide Attempt
Trauma/PTSD
Grief and Loss
Support Services
Mental Health Peer Support
Trauma Support
Grief Support
Care Giver Support
Surviving Suicide Support
NAMI Peer Support
Educational Services
Educational Advocacy
IEP/504/SST Support
Family Services
Educational Services
Groups or Classes interested in attending:
Trauma Support
Women's Wellness
Veterans & First Responders
Mental Health Management
NAMI Mental Health Peer Services
Other Family Resources needed:
I would like to to volunteer.
I want to subscribe to the newsletter.
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