Request an Appointment

1
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
2
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
Which type of appointment/service are you requesting?* This field is required.
Individual (For yourself; 12+ years old)
Agency Mandated Wellness Check
Couples Counseling
Minor Counseling (Under 12 Years Old)
Assessment (Seeking diagnosis, Self-pay only)
4
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
5
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
6
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
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
Fort Lupton Police Department
Fountain 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
7
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
Douglas County Sheriffs Office
Drug Enforcement Agency
El Paso County Sheriffs Office
Elbert County Sheriffs Office
Englewood Police Department
Erie Police Department
Fort Lupton Police Department
Fountain 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
8
Tell us the agency you are currently associated with or the most recent one you were associated with.* This field is required.
9
Minor's Name* This field is required.
First Name
Last Name
10
Minor's Age* This field is required.
11
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
12
Additional Guardian's Information* This field is required.
Their First Name
Their Last Name
Please enter their email
Please enter their phone
13
Please upload the document outlining shared legal medical decision-making authority for this minor.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
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
15
Are you or your significant other a current employee or volunteer at a public fire service in Colorado?* This field is required.
YESNO
16
Are you a current employee or volunteer at a public fire service in Colorado?* This field is required.
YESNO
17
You may be eligible for the Colorado Firefighters Benefit Trust. You will be billed $150 per session if you choose this option. Once paid, you can file a claim with the trust for reimbursement. Would you like to utilize the Colorado Firefighters Benefit Trust?* This field is required.There are some additional stipulations that can be reviewed here. If you'd like to set up direct billing please follow the instructions available on the Behavioral Health Trust's website.
YESNO
18
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
19
EMS Certification Number* This field is required.You can get the certification number on this website.
20
It looks like you qualify for funding through Path4EMS! Can we send your information to Path4EMS for verification?* This field is required.
YESNO
21
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. You will also be enrolled in autopay.
Self-Pay.
It's A Calling Foundation.
22
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
23
Please enter a dollar amount you can currently pay to cover the It's A Calling Foundation co-pay.* This field is required.
24
Financial Need Statement.* This field is required.Please provide a statement explaining why you need a reduced or removed co-pay.
Huge
Large
Normal
Small
Ok
Ok
25
Based on the information you've provided you are likely eligible for both the Colorado Firefighter Benefit Trust and Path4EMS. We recommend using Path4EMS first, then switching to the Trust if you use all of the Path4EMS benefits, you would not have to cover anything out of pocket until you start using the Trust. Would you like to use Path4EMS first?* This field is required.
YESNO
26
Are you currently covered by UnitedHealthcare through Douglas County Sheriffs Office?* This field is required.
YESNO
27
UnitedHealthcare Insurance Card* This field is required.Please upload a clear photo of the front and back of your insurance card.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
28
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 Check
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
29
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 North office or CoSprings office.
Landmark Office (5350 S Roslyn Street Suite 240, Greenwood Village)
North Denver (901 E 68th Ave, Denver) * limited availability
Colorado Springs (3210 E Woodmen Rd, Ste 110, Colorado Springs) * limited availability
30
Provide the name and ID number for the individual employed at El Paso County Sheriff's Office* This field is required.
31
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
Landmark Office (5350 S Roslyn Street Suite 240, Greenwood Village)
North Denver (Limited Availability)
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)
32
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
33
Additional Comments.Please let us know if you have any questions. If you have a participant number from PATH4EMS, please provide that here.
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: