Please enter the following information to complete the referral form.  If you have any questions, please contact Rebecca Sauter, Project Reentry Coordinator at rsauter@ptrc.org.  

 

 

Client Profile Information

Last Name

 *

Last Name

First Name

 *

First Name

Middle Name

Middle Name

Suffix

Suffix

Date of Birth (MM/DD/YYYY)

 *

Date of Birth (MM/DD/YYYY)

Opus #

Opus #

Contact Number

 *

Contact Numberext.

Address

Street

 *

Street

City

 *

City

State

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Zip Code

Referral Information

Referral Date (MM/DD/YYYY)

 *

Referral Date (MM/DD/YYYY)

Referral Source

 *

Referral Source

Council Member

Probation

Goodwill

Other

If this referral source is a Council Member, please provide your name and agency name.

If this referral source is a Council Member, please provide your name and agency name.

Individual Name

Agency Name

Email Address

If the referral source is probation, please pick the current status.

If the referral source is probation, please pick the current status.

60 day Post Release unemployed workshop

90 day probation unemployed workshop

RSS graduate

Post Release homeless/unemployed

If the referral source is probation, please indicate supervision level and provide contact information. 

If the referral source is probation, please indicate supervision level and provide contact information.

OL1

OL2

OL3

OL4

OL5

Probation Officer Name

Contact Number

Email Address

If the referral source is "Other", please provide your contact information.

If the referral source is "Other", please provide your contact information.

Name

Contact Number

Is the prospective participant currently in custody?

 *

Is the prospective participant currently in custody?

Yes

No

If you answered Yes to the above question, please provide us with the name of the facility.

If you answered Yes to the above question, please provide us with the name of the facility.

 NCDPS Contact Information

NCDPS Contact Information

NCDPS Case Manager Name

NCDPS Case Manager Contact Number

NCDPS Case Manager Email

Reason for Referral 

 *

Reason for Referral

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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