Referral Form

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Date* This field is required.
Date
Month
Day
Year
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Referral Time:* This field is required.
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Hour
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Minutes
AM
AM
PM
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Referring Agency?* This field is required.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'.
4
Name (of person being referred)* This field is required.If you are filling out this form on someone else's behalf, please enter their name here and provide your own name and contact information in the section at the end.
First Name
Last Name
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Email (of person being referred)
example@example.com
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Phone Number (of person being referred)
Please enter a valid phone number.
7
Date of Birth* This field is required.
Date
Month
Day
Year
8
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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County of Residence?* This field is required.
Adams County
Ashland County
Barron County
Bayfield County
Brown County
Buffalo County
Burnett County
Calumet County
Chippewa County
Clark County
Columbia County
Crawford County
Dane County
Dodge County
Door County
Douglas County
Dunn County
Eau Claire County
Florence County
Fond du Lac County
Forest County
Grant County
Green County
Green Lake County
Iowa County
Iron County
Jackson County
Jefferson County
Juneau County
Kenosha County
Kewaunee County
La Crosse County
Lafayette County
Langlade County
Lincoln County
Manitowoc County
Marathon County
Marinette County
Marquette County
Menominee County
Milwaukee County
Monroe County
Oconto County
Oneida County
Outagamie County
Ozaukee County
Pepin County
Pierce County
Polk County
Portage County
Price County
Racine County
Richland County
Rock County
Rusk County
Saint Croix County
Sauk County
Sawyer County
Shawano County
Sheboygan County
Taylor County
Trempealeau County
Vernon County
Vilas County
Walworth County
Washburn County
Washington County
Waukesha County
Waupaca County
Waushara County
Winnebago County
Wood County
Unknown
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Member of LGBTQ+ Community?* This field is required.
YESNO
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Gender Identity?* This field is required.
Cisgender Woman
Cisgender Man
Trans Woman/Trans Feminine (M2F)
Trans Man/Trans Masculine (F2M)
Non-Binary
Agender
Gender Fluid
Two Spirit
Declined Response
Other
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Pronouns* This field is required.
He/Him/His
She/Her/Hers
They/Them/Their
Other
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Primary Language* This field is required.
English
Spanish
Hmong
Chinese
German
Other
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Preferred type of contact?
Calling
Texting
In-Person
Telehealth
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Currently on Probation or Extended Supervision?* This field is required.
YESNO
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If yes, what is your DOC NumberIf unknown leave blank
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Do you identity as Hispanic/Latinx? * This field is required.
YESNO
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Race/Ethnicity?* This field is required.Please check all that apply.
Black/African American
White/Caucasian
Latinx/Hispanic
Indigenous
Pacific Islander/Native Hawaiian
Asian
Middle Eastern
Declined Response
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Have you/are you serving in the armed forces? * This field is required.
YESNO
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Are you an expectant parent?* This field is required.
YESNO
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Are you a participant in a Diversion Program?* This field is required.
YESNO
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If yes, which program? If unknown leave blank
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Substance Information* This field is required.
Alcohol
Amphetamines - Rx
Benzodiazapines - Rx
Cannabis
Cannabis - Synthetic
Cocaine
Cocaine - Crack
Heroin
Inhalants
Ketamine
LSD
MDMA
Methamphetamine
Methadone - Non-Rx
Mushrooms
Opioids - Rx
Opioids - Synthetic
Over the Counter Meds
PCP
Steroids
Tobacco
Xylazine
No Specific Drug
Other
Unknown
Declined Response
In the past year what substances have you struggled with? (Select all that apply)
Please Select
Please Select
Alcohol
Amphetamines - Rx
Benzodiazapines - Rx
Cannabis
Cannabis - Synthetic
Cocaine
Cocaine - Crack
Heroin
Inhalants
Ketamine
LSD
MDMA
Methamphetamine
Methadone - Non-Rx
Mushrooms
Opioids - Rx
Opioids - Synthetic
Over the Counter Meds
PCP
Steroids
Tobacco
Xylazine
No Specific Drug
Other
Unknown
Declined Response
What is your primary substance of concern?
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If the option is available, do you have a preference for your coaches gender, race/ethnicity, age, etc?
25
Upload any necessary filesPlease include any referral , ROI, Treatment Plan, or any other appropriate documents.
Drag and drop files here
Select files to upload
Cancelof
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NameName of individual completing this form on behalf of another
First Name
Last Name
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EmailEmail of individual completing this form on behalf of another
example@example.com
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Phone NumberPhone number of individual completing this form on behalf of another
Please enter a valid phone number.
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Integration Fields:

Below are autopopulated fields. These are hidden from the individual filling out the form and used for integration purposes only.
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Program Budget
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Program Qualifier
Not Applicable
Please Select
Not Applicable
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Reengaging in Services
Unknown
Please Select
Unknown
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Referral Soure
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Business ID* This field is required.
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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.
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