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. 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 request 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.

Drop in Monday, Wednesday & Thursday from 11:30am-12:30pm or Tuesday & Friday from 2:00-3:00pm for a personalized consultation with a counselor from the Counseling Center.

Join here via zoom: https://zoom.us/j/92996807583

Please review Virtual Office Hours Consent prior to attending.

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 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*

Schedule Appointment w/Case Manager*

Yes: meet to understand the process, review personalized list and submit requests for consultations to off-campus counselors (please list availability below)
No: receive personalized list and assistance by email

Additional Information:*

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

CAPTCHA

Initial Request to Connect