This referral form is for probation officers, clinics, and case managers to connect clients with recovery and empowerment programs. All submissions are confidential and handled with care.

First Name

Last Name

Date of birth

Email *

Phone *

Please select the option that best describes you as the referrer:

Primary Care Physician (PCP)/Medical Doctor

Psychiatrist

Psychologist/Therapist

Licensed Addiction Counselor (Substance Abuse Counselor)

Social Worker (or Clinical Case Manager)

Emergency Room/Hospital Staff (Nurse, Discharge Planner, etc.)

Parole or Probation Officer

Court Official (Judge, Court Liaison, etc.)

Law Enforcement/Police Officer

Correctional Facility Staff

Spiritual/Religious Leader (e.g., Pastor, Priest, Rabbi, Church Elder)

Family Member (e.g., Parent, Spouse, Sibling)

Friend/Acquaintance

Full Name of Referrer (Your Name) *

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