Clone of Referral Form

Referral Form for Peer Support Services

Hi there, please fill out and submit this form to get connected with a peer support specialist. Please be aware at times we do have a waitlist.
Is this Michelle Fox?
Is this Jadin

You indicated you are submitting this form on behalf of another individual. Please enter your contact information in this section.

If you are filling this out for yourself - please click back to return to the previous screen and update your answer.
Name (Of person MAKING referral)
Email (Of person MAKING referral)
example@example.com
Phone Number (Of person MAKING referral)
Please enter a valid phone number.Format: (000) 000-0000.

You indicated you are Safe Communities Employee.

If you are not employed by Safe Communities - please click back twice to update your answer.
Was this a Support Line call?
Is this case being closed and reopened to another Safe Communities program/funding?
Is this a MARI Outreach Referral?
Should this case be assigned to you?

Information for Participant receiving services.

If you are filling this form on someone else's behalf, please enter THEIR information for the remainder of the form.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Time:

Hour Minutes

AM/PM Option
Referring Agency?
Please indicate who referred you to Safe Communities. If you are re-engaging with services or were already aware of us, you may enter 'self'.

Upload any necessary files

Please include any referral , ROI, Treatment Plan, or any other appropriate documents.
Cancelof
Please be aware that we sometimes have a waiting list. Processing your request and adding you to the list may take 24–48 hours. If you have not heard from a peer specialist within two weeks, please call our 24/7 helpline at 608-228-1278 to speak with an on-call peer specialist for an updated wait time. You may also use this number for support while you wait for an available peer specialist.
Integration Fields:

Below are autopopulated fields. These are hidden from the individual filling out the form and used for integration purposes only.
Referral Soure
Program Budget
Business ID
Program Qualifier
Legal Sex
Should be Empty:

Referral Form/Request for Services