Referral for Assessment

Client Information

Wellness Court & AIIM Program

Please be sure to fill out all * required fields: 
Referral Type, Client Name, Client Phone, Date of Birth, Client location at the time of referral, Release Form upload

Referral Type*

Please download, complete and bring in this AIIM Pre-Screen Release of Information document.

Please download, complete and bring in this Wellness Pre-Screen Release of Information document.

Referral Information
Assessment Information
Mental Health Diagnosis (may be self reported)

*Required - Release Form upload: Download the AIIM Release form or the Wellness Court Release form, fill out, scan and save it to your PC. Then click the Choose File button below, and select the filled-out file.

One file only.
100 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx, txt.
Other Pertinent Information Attached (please check all that apply)
Maximum 3 files.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx, txt.

Referrals and documents may also be faxed to 970-498-7490

Please complete the Wellness Court Release for ALL referrals for both AIIM and Wellness Court. At this time all referrals are going through the same screening process. Please submit the release and referral by clicking the green Submit button above, or fax them to (970) 498-7490. You may also email them to Dianne Bacorn at bacorndm@co.larimer.co.us, Ted Pierce, piercete@co.larimer.co.us or Jim Fox, foxjl@co.larimer.co.us.

If you have any questions regarding the referral process, please contact Dianne Bacorn at 970-498-7581 or bacorndm@co.larimer.co.us or Ted Pierce at piercete@co.larimer.co.us or Jim Fox (970) 498-7557, or foxjl@co.larimer.co.us.