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Make a Referral

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.

You can make a referral three ways:

  • Submit an online request via the referral form below
  • Call 402.371.0220
  • Fax 402.644.4593

 

Referral Form

To refer yourself or someone else, complete and submit this form to The Well. We will respond to you the same day. If you need immediate help, call 911.

* indicates required fields

Personal Information

Legal Name*
Address*
Date of Birth*

Referral Source

(if self-referral, you may leave the following blank)
Person Making Referral

Urgent Information

Is the person experiencing thoughts of harm to self or others?
Does the person believe they are unsafe right now?
Does the person have dependent children?
If yes, are the children currently safe?

Other Important Information

If you do not know or do not have insurance, please put N/A. Not having insurance does not prevent you from receiving services.
Intravenous use?
Last date of use
This field is for validation purposes and should be left unchanged.