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Make a Referral | Norfolk, Columbus, & West Point, Nebraska

Potential clients of The Well may be referred to us by a professional support person or they may self-refer. Those in need of an updated mental health or substance use disorder assessment may contact The Well’s Outpatient Program below.

Open Access (Outpatient Services Without an Appointment):

The Well offers Open Access hours for individuals who would like to walk in and connect with outpatient services without scheduling an appointment in advance. During Open Access, individuals can receive a substance use assessment, attend a walk-in counseling session, or connect with community support or crisis response services. New clients are welcome!

Please note that mental health assessments are not completed during Open Access hours and must still be scheduled in advance. However, individuals who are planning to schedule a mental health assessment are welcome to stop in during Open Access to complete intake paperwork.

Norfolk

Mondays from 12:00 p.m. – 5:00 p.m.
Wednesdays and Fridays from 8:00 a.m. – 1:00 p.m.

Columbus

Wednesdays 8:30 a.m. – 1:00 p.m.

If you are in crisis or need services immediately, call our 24/7 number 1-888-370-7003.

Referral Form

To refer yourself or someone else, complete and submit this form to The Well. If you are in a mental health crisis, please call our Crisis Response line at 1.888.370.7003. 24 hours a day, 7 days a week. If you are in need of emergency medical attention, please call 911.

* indicates required fields

This field is for validation purposes and should be left unchanged.

Personal Information

What is your relationship to the person needing services?*

I am referring myself

I am a Legal Guardian of a minor child

I am the Legal Guardian of adult

I am a Family Member

I am a Friend

I am a provider referring someone to services

I am a Well Team Member helping a client complete the referral form

What problems are you/they experiencing that led you to reach out for help?*

What services are you looking for?*

Counseling

Community Support

Medication management/psychiatry

IOP

Evaluation/assessment

Dual disorder residential (Level 3.5)

Intermediate residential (Level 3.3)

Mommy and Me residential

I don’t know

If you are in crisis or need services immediately, call our 24/7 number 1-888-370-7003.

Legal Name*

First Last

Preferred Name

Pronouns

Phone Number*

If you do not have a phone number, please write ‘none’ in the field below.

Email Address

Date of Birth*

Address*

At this time we are not able to serve clients outside of the Nebraska area. If you relocate to Nebraska, please reach out again and we would love to be able to work with you!

Street Address Address Line 2 City State ZIP Code

Social Security Number*

If you do not have a social security number, please write none in the field below.

Gender*

Male

Female

No Preference

Transgender

Non-Binary

Gender Variant/Non-conforming

Prefer not to answer

Primary Language*

English

Spanish

Other

Primary Language – Other

Referral Source

Person Making Referral

First Last

Relationship to Person Being Referred

Agency of Person Making Referral

Phone

Mental Health / Substance Use / Family information:

Are you (or is the person) experiencing thoughts of harm to self or others?

Yes

If yes, please describe.

Is the person experiencing delusions or hallucinations that increase their risk?

Yes

Unknown

If yes, please describe

Are you (or is the person) using substances or alcohol?

Yes

If yes, what substances are you/they using?

How Long Since Last Use?

Within the last 24 hours

1 to 3 days ago

4 to 7 days ago

More than a week ago

More than 1 month ago

Not sure

Are you/they using intravenously (IV)?

Yes

If yes, when was the date of last IV use?

Have you/they ever been diagnosed with any of the following:

Schizophrenia/Schizoaffective

Severe Major Depressive Disorder

Bipolar Disorder

Date of most recent substance use evaluation, can be approximate if needed

Do you (or the person) have dependent children?

Yes

If yes, are they in your care?

Yes

Is there any other information you'd like to share with us?

Interim Service Information

Team Member Instructions (do not read to client):
When submitting a referral by phone or in person, use the script below to inform the client of the required health and safety disclosure.

Team Member Script (read aloud to client):
“Before we finish, I need to share some information with you. We are required by federal law to provide a health and safety notice that covers risks related to substance use, infectious diseases like HIV, Hepatitis, and TB, and pregnancy. I don’t need to read it word-for-word unless you want me to. I can read it to you now, send you a copy to review later, or you can choose not to hear it at this time. Just let me know what you’d prefer.”

Interim Service Information*

By checking this box, you acknowledge receipt of the following information:

We are required by federal law to provide the following information to you. Please review this information and let The Well Referrals Team or your provider know if you have questions.

Injecting drugs increases the risk of getting an infectious disease like HIV and Hepatitis because these infections are transmitted through the same blood and body fluids used for injecting. Do not share needles or any of drug preparation equipment. Injecting also increases the chance of abscessed bacterial infections, scarring, arterial damage, overdose, and death. When people inject drugs, drink alcohol, or use other drugs, they increase the risk of getting HIV, Hepatitis, or a Sexually Transmitted Infection (STI) because these infections are not only in blood, but semen and vaginal fluids. Those using substances may engage in high-risk behaviors like condomless sex, sex for money or drugs, or having many partners. Once a person is infected, they can transmit HIV, Hepatitis, and STDs to their intimate partners. It can also be spread to an unborn child if you or your partner are pregnant

Tuberculosis (TB) is an airborne infectious disease that can also be easily spread by individuals that inject drugs. TB usually attacks the lungs and is spread through coughing and sneezing. Signs of TB include coughing, fevers, coughing up blood, night sweats, feeling tired, & weight loss. TB can be treated & cured with medical help. To lower the chance of giving TB to someone, see a medical provider as soon as possible. They will give you medicines and information about wearing a mask to keep people safe.

It’s important to know that drug use can harm an unborn child.

Drinking alcohol or using drugs during pregnancy can cause problems like miscarriage, stillbirth, and lifelong physical, behavioral, and intellectual disabilities for the child.
Someone who is pregnant and infected with HIV can safely take medicines that can keep the baby from getting HIV. If a mother knows she has HIV, the baby has a better chance of not getting it. Also, the mother will know not to breastfeed, as this can give a baby HIV also.

To find places where you can get screened for HIV, Hepatitis, STDs, and TB, go to www.gettested.cdc.gov, ask The Well Referrals Team or your provider, or contact a local public health department.

Elkhorn Logan Valley Public Health Department (Norfolk, West Point, & surrounding communities): 877-379-4400

East Central District Health Department (Columbus & surrounding communities): 402-562-7500

Interim Service Information*

By checking this box, I confirm that the individual being referred has been informed of the Interim Service Acknowledgment and that they were offered the opportunity to review it.

Interim Service Information*

By checking this box, I confirm that the federally required Interim Services Health & Safety Disclosure was offered and made available to the client, and the client acknowledged receipt.