Request an Appointment

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I understand that CODE-4 Counseling does not provide crisis counseling and that if I or someone I know is experiencing a mental health crisis I should dial 988 or 911 for medical emergencies. I also understand that I might not receive a response to this submission for up to two business days.
I Understand
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Your Information* This field is required.
First Name
Last Name
Please enter your email, we recomend using your personal email to avoid missing our emails and to further protect your privacy.
Please enter your phone
3
What State do you currently live in?* This field is required.
Colorado
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Which type of appointment/service are you requesting?* This field is required.
Individual (For yourself; 12+ years old)
Agency Mandated Wellness Visit
Couples Counseling
Minor Counseling (Under 12 Years Old)
Assessment (Seeking diagnosis, Self-pay only)
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Profession / Relationship* This field is required.How are you connected to the first responder / medical community, this can be your profession or your relationship to the first responder or medical professional.
Please Select
Please Select
Child/Dependent
Parent
Spouse / Partner
Behavioral Health Professional
Coroner
Co-Responder
Dispatch
Emergency Medical Technician
Fire Fighter
Hospitalist
Medical Assistant
Military
Nurse Practitioner
Paramedic
Peace Officer
Physician
Physician Assistant
Private Security
Professional Staff (i.e., Records, Detentions, Administration)
Registered Nurse
Search and Rescue
Surgeon
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How long have you been in this profession?* This field is required.(Not necessarily your current agency or organization)
Please Select
Please Select
< 1
1 - 5
6 - 10
11 - 15
16 - 20
21 +
Retired
Veteran / Former
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Agency* This field is required.
Please Select
Please Select
I don't see my agency listed.
23rd Judicial District
3rd Judicial District
Adams County Fire Department
Adams County Sheriffs Department
Alliance Police Department
Arapahoe County Sheriffs Office
Archuleta County Sheriffs Office
Avon Police Department
Boulder Fire, City of
Brighton Police Department
Brush Police Department
Buena Vista Police Department
CarePoint Health
Castle Rock Fire And Rescue Department
Castle Rock Police Department
Cherry Hills Police Department
Cheyenne County Sheriffs Department
Childrens Hospital
Commerce City Police Department
Cortez Police Department
Denver International Airport
Douglas County Sheriffs Office
Drug Enforcement Agency
Eagle County Sheriffs Office
El Paso County Sheriffs Office
Elbert County Sheriffs Office
Englewood Police Department
Erie Police Department
Federal Heights Police Department
First Responders Children's Foundation
Fort Lupton Police Department
Fountain Police Department
Frasier Winter Park Police Department
Garfield County Sheriffs Office
Glendale Police Department
Glenwood Springs Police Department
Grand County Sheriffs Office
Hudson Police Department
Jefferson County Sheriffs Office
Littleton Police Department
Lochbuie Police Department
Logan County Sheriffs Department
Lone Tree Police Department
Moffat County Sheriffs Office
Montrose County Sheriffs Office
Morgan County Sheriffs Office
North Metro Fire Rescue District
New Castle Police Department
Otero County Sheriffs Office
PalAmerican Security
Parker Police Department
Prowers County Sheriffs Office
Saguache County Sheriffs Department
South Adams County Fire Department
South Metro Fire Rescue
Summit County Sheriffs Office
Thornton Police Department
Vail Police Department
Windsor Police Department
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Agency* This field is required.
Please Select
Please Select
I don't see my agency listed.
23rd Judicial District
Adams County Sheriffs Department
Arapahoe County Sheriffs Office
Archuleta County Sheriffs Office
Avon Police Department
Boulder Fire, City of
Brighton Police Department
Brush Police Department
Buena Vista Police Department
Castle Rock Fire And Rescue Department
Castle Rock Police Department
Cheyenne County Sheriffs Department
Commerce City Police Department
Cortez Police Department
Cortez Police Department
Denver International Airport
Douglas County Sheriffs Office
Drug Enforcement Agency
El Paso County Sheriffs Office
Elbert County Sheriffs Office
Englewood Police Department
Erie Police Department
First Responders Children's Foundation
Fort Lupton Police Department
Fountain Police Department
Frasier Winter Park Police Department
Garfield County Sheriffs Office
Glendale Police Department
Glenwood Springs Police Department
Grand County Sheriffs Office
Hudson Police Department
Jefferson County Sheriffs Office
Littleton Police Department
Logan County Sheriff Department
Lone Tree Police Department
Moffat County Sheriffs Office
Montrose County Sheriffs Office
Morgan County Sheriffs Office
New Castle Police Department
Otero County Sheriffs Office
Parker Police Department
Prowers County Sheriffs Office
Saguache County Sheriffs Department
South Adams County Fire Department
South Metro Fire Rescue
Summit County Sheriffs Office
Thornton Police Department
Windsor Police Department
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First Responder Children’s Foundation

We are proud to partner with the First Responder Children’s Foundation (FRCF) to provide counseling services at no cost to eligible families. This partnership helps ensure children of first responders have access to high-quality, confidential mental health support.

Visit the following link and fill out the request form:

https://1strcf.org/get-mental-health-support/

This application allows the First Responder Children’s Foundation to verify eligibility and initiate the referral process.

You will need to put that referral ID in the field on the following prompt and/or email it to info@code4counseling.com. Both the FRCF form and this appointment request need to be completed.
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First Responders Children's Foundation Referral ID* This field is required.Please provide the referral ID that was provided to you after you submitted the referral screening form on the FRCF website (https://1strcf.org/get-mental-health-support/). If you have not submitted the referral form or have not received an ID yet, please explain in the comments. Sessions cannot be scheduled until the funding is verified.
Example: FRCF00000
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Tell us the agency you are currently associated with or the most recent one you were associated with.* This field is required.
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Are you currently covered by the UnitedHealthcare Doctor's Plan through the Douglas County Sheriff's Office?* This field is required.Must say Doctors Plan on your card in the lower right corner. Select "NO" if you are currently on the High Deductable Plan.
YESNO
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Douglas County Sheriff's Office does not cover counseling services outside of the UHC Doctors Plan.* This field is required.The current self-pay rate is $115 per session. If you choose to use the It's A Calling Foundation, there is a $40 a session co-pay, and you are limited to pre-licensed therapists that are directly supervised by licensed providers. Automatic payments are required for both self-pay and the IACF co-pay.
Self-pay (including HSA card)
It's A CallingFoundation
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Minor's Name* This field is required.
First Name
Last Name
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Minor's Age* This field is required.
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Is there a court order in place outlining shared legal medical decision-making authority for this minor?* This field is required.If 'No' you may be asked to provide additional documentation.
YESNO
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Additional Guardian's Information* This field is required.
Their First Name
Their Last Name
Please enter their email
Please enter their phone
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Please upload the document outlining shared legal medical decision-making authority for this minor.* This field is required.
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Max. file size: 10.6MB
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Spouse / Partners Information* This field is required.You will both be required to fill out forms during the intake process.
Their First Name
Their Last Name
Please enter their email
Please enter their phone
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Are you or your significant other a current employee or volunteer at a public fire service in Colorado?* This field is required.
YESNO
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Do you or someone in your immediate family have a current Emergency Medical Service (EMS) certification in Colorado?* This field is required.You can search this website to verify the certification.
YESNO
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EMS Certification Number* This field is required.You can get the certification number on this website.
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It looks like you qualify for funding through Path4EMS! Can we send your information to Path4EMS for verification?* This field is required.
YESNO
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It does not look like we have a pre-existing relationship with the agency you have identified. We now have two options to look at, Self-pay, and the It's A Calling Foundation.* This field is required.The current self-pay rate is $115 per session. If you choose to use the It's A Calling Foundation, there is a $40 a session co-pay and you are limited to pre-licensed therapist that are directly supervised by licensed providers. Automatic payments are required for both self-pay and the IACF co-pay.
Self-Pay.
It's A Calling Foundation.
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Can you currently afford the $40 per session co-pay with the It's A Calling Foundation?* This field is required.If you are not able to afford the co-pay, we will need to submit your information to the It's A Calling Foundation for approval to reduce or remove the co-pay.
YESNO
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Please enter a dollar amount you can currently pay to cover the It's A Calling Foundation co-pay.* This field is required.
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Financial Need Statement.* This field is required.Please provide a statement explaining why you need a reduced or removed co-pay.
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UnitedHealthcare Insurance Card* This field is required.Please upload a clear photo of the front and back of your insurance card.
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Select files to upload
Max. file size: 10.6MB
Browse Files
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Primary Concern* This field is required.Please select from the following options that best describes why you are requesting an appointment at this time.
Please Select
Please Select
Suicidal Ideation / Non-fatal Behaviors
Agency Required Wellness Visit
Behavioral Addiction
Critical Incident
Comprehensive Assessment (Seeking diagnosis, Self-pay only)
Family / Parenting
General Stress
Grief / Loss
Identity / Belonging
Intimate Relationship
Mood (Anxiety / Depression)
Neurodiversity
Trauma
Occupational Stress
Physical Injury / Health
Retirement / Transition
Self-Growth
Sleep Disturbances
Substance Use
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Location* This field is required.Please select the locations that you are able to accommodate. Selecting telehealth will decrease potential wait times.
Telehealth *Can be accommodated quicker than selecting just physical offices.
Landmark/DTC (5350 S Roslyn Street Suite 240, Greenwood Village)
Lakewood (200 Union Boulevard, S Union St Suite 200, Lakewood)
Colorado Springs (3210 E Woodmen Rd, Ste 110, Colorado Springs) * limited availability
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Provide the name and ID number for the individual employed at El Paso County Sheriff's Office* This field is required.
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Location (J)* This field is required.Please select the locations that you are able to accommodate. Selecting more options here may decrease your wait times.
Telehealth *Can be accommodated quicker than selecting physical offices.
Landmark/DTC (5350 S Roslyn Street Suite 240, Greenwood Village)
Lakewood (200 Union Boulevard, S Union St Suite 200, Lakewood)
JEFFCO Wellness Center
Colorado Springs (3210 E Woodmen Rd, Ste 110, Colorado Springs)
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Location (E)* This field is required.Please select the locations that you are able to accommodate. Selecting more options here may decrease your wait times.
Telehealth *Can be accommodated quicker than selecting physical offices.
Landmark/DTC (5350 S Roslyn Street Suite 240, Greenwood Village)
Lakewood (200 Union Boulevard, S Union St Suite 200, Lakewood)
El Paso County Sheriffs Office (Availability Mon to Thu, no in-person sessions on Fridays)
Colorado Springs (3210 E Woodmen Rd, Ste 110, Colorado Springs)
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Which days are you available?* This field is required.Selecting more options here may decrease your wait times.
Monday
Tuesday
Wednesday
Thursday
Friday
Rotating Schedule
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Additional Comments.Please let us know if you have any questions. If you have a participant number from PATH4EMS, please provide that here.
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