Champions Referral Form
Please complete this form for all referrals for Champions Treatment Programs. A referral does not guarantee suitability for programming, as suitability is based on eligibility assessment and determination by the Champions staff. Once all information has been submitted a Champions staff person will contact you and the prospective client. Thank you for your interest in Champions!
Email address *
Name (Person Being Referred) *
Your answer
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
Telephone Number *
Your answer
Jail Custody Status *
Required
Release Date (if in custody)
MM
/
DD
/
YYYY
CPS Referral (List CPS Worker Name & Email)
Your answer
Probation Referral (List Probation Officer Name & Email)
Your answer
Parole Referral (List Parole Officer Name & Email)
Your answer
Services Requested *
Required
Additional Comments:
Your answer
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