Care Coordination Request

If you feel that you need immediate assistance, please contact Colorado Crisis Services at 1-844-493-8255 or text TALK to 38255. Outside of Colorado, call or text 988. For life threatening emergencies, please dial 911.

*Required Field

Name*

First Last

Preferred Name/Pronouns

Mines Email Address Required (others go to junk mail)*

Enter Email Confirm Email

CWID*

Phone #*

Current City*

Golden

Current State*

Colorado

Please choose from the service options below*

Choose this option to schedule an appointment with a counselor for a 15 minute phone consultation to determine next steps which may include therapy sessions, groups, workshops and other resources or referrals.

Reason for Request*

Please list a brief reason for your request so that we can connect you with the appropriate counselor or resource.

Availability*

Please list times that you are available M-F 8:00am-4:45pm MST to receive a 15 minute phone consult from a Mines counselor. We will schedule you in the next available appointment that matches your request and respond by email with your appointment date and time.

Choose this option if you would like to receive a personalized referral list to off-campus counselors.*PLEASE NOTE: If you like to speak with a Mines counselor for guidance, select "initial phone consultation" from the drop down above.

Health Insurance Coverage*

Receive & Review Options:*

Receive personalized list & assistance by email
Receive personalized list by email & meet with case manager (please list availability below)

Additional Information:*

Please provide any specifics important to you in your search for a counselor (i.e. location, specialties, language, gender, etc.)

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Initial Request to Connect