Dickinson Community Health Provider Referrals

First Name Required

Provider first name - or - name of practice

Last Name

Email Required

Practice Address Required

Specialty? Required

Do you accept insurance? Required

Yes

No

Do you offer a sliding scale? Required

Yes

No

What are your practice hours? Required

Do you offer telemedicine/teletherapy? Required

Yes

No

What are your credentials (MD, DO, LCSW, PHD, PsyD, LPC, ARNP etc.)? Required

Are you interested in attending a lunch and learn with Wellness Staff to learn more about how we can collaborate? Required

Yes

No

Would you like us to advertise your information on the Wellness Center website for students who are searching for outside providers? Required

Yes

No

Do you offer groups? If so, please provide the group type and schedule.

Is there anything else you'd like us to know?

Practice Specifics