Make a Referral

Completing this digital referral will ensure the fastest response. If unable to complete your referral on our website, please fax referrals to (307) 265-7727.

BE ADVISED: This form is monitored 8 a.m. to 5 p.m., Monday through Friday. Responses are provided the next business day. If you are experiencing a crisis, please call our 24-hour Crisis Line at 307-259-9442.

Are you requesting services for yourself or a loved one?(Required)

Yes, for myself or a loved one.

No, I’m making a referral from a partner organization.

Is this a referral from a drug court or detention center?(Required)

Yes

No

Which partner organization is making this referral? Check one.(Required)

DFS

Law Enforcement

Probation & Parole

Re-Entry

School

Primary Care or Emergency Department

Other

Partner Organization:(Required)

Are the requested services for a minor or legal adult?(Required)

Minor

Legal Adult

Are you requesting services for yourself?(Required)

Yes

No, I’m submitting this form for someone else.

Do you have a legal guardian?(Required)

Yes

No

Name of legal guardian(Required)

First Last

Guardian’s relationship to you(Required)

Phone(Required)

Email

"Form 2" (This will be deleted)

Is this referral for a child or an adult?(Required)

Child

Adult

"Form 3" (This will be deleted)

Is this referral for a child or an adult?(Required)

Child

Adult

Hope is Here

Whether you’re an individual seeking services for yourself or a loved one, or an organization referring someone for treatment, this is the place. Simply complete the form below, and click “submit.” If you need assistance in requesting services, please call (307)237-9583.

"Form 2" (This will be deleted)

"Form 3" (This will be deleted)