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!
Name (Person Being Referred)
Date of Birth
Jail Custody Status
Out of Custody
Release Date (if in custody)
CPS Referral (List CPS Worker Name & Email)
Probation Referral (List Probation Officer Name & Email)
Parole Referral (List Parole Officer Name & Email)
Batterer's Intervention Program (BIP)
Child Abuse Treatment Program
Multidimensional Family Therapy
Nurturing Parenting Program
Parent-Child Interactive Therapy (PCIT)
Relationship Enhancement Program
Residential Treatment (Samuel's House or Hannah's House)
Substance Abuse Treatment (Outpatient or Intensive Outpatient)
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