North Star Behavioral Health

North Star Information Request for Professionals

Please do not use this form, or electronic mail, to discuss your medical condition, medical history, or private health information. It is not encrypted, and we cannot guarantee your privacy if you include sensitive information about yourself.

I would like to find out more about North Star Behavioral Health programs and services as described below. Please contact me with more information.

Your Name:	__________________________
Title:	__________________________
Organization:	__________________________
Address:	__________________________
City:	__________________________
State:	__________________________
Zip:	__________________________
Telephone (office/cell if preferred):	__________________________
Fax:	__________________________
E-mail:	__________________________
Best time time of day to reach me:	__________________________a.m./p.m.
Best method to reach me:	__________________________
I would like more information about: Hospital treatment Child Teen Family Program
Residential treatment	Wilderness-based residential treatment
Other (please describe)	__________________________
Additional Information:	__________________________ __________________________ __________________________ __________________________

Please print and fax completed form to (907)279-1438. A North Star staff member will contact you. Thank you for your interest.

(907) 258-7575
(800) 478-7575 (in Alaska)
northstarinfo@uhsinc.com

Hospital & Residential Treatment Centers • Anchorage: DeBarr · Bragaw; Palmer
907.258.7575 | 800.478.7575 · 24-hour crisis