Agent / Agency Referral Form

This form is for the agent to complete to request client contact, introduction and follow-up to services from a PEER NAVIGATOR. Get Connected services are FREE for those who chose to engage in services.

 Get Connected serves males and females from ages 12+ years old who have been impacted by incarceration. Our goal is to provide one-on-one support for those individuals who struggle with barriers during their reentry experience.

Eligibility criteria as follows: Client must be moderate to high risk; client must provide their Risk Score and Parole Board or Court Orders to receive services. 

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Referral Requirement - Signed Confidentiality/ Release of Information /  Share board orders & Risk and Needs Assessment SCORES / if you answered YES to all of the categories then you can proceed to filling out this FORM *
Agent / Agency Name *
Agent / Agency Email
Referral Name *
Referral Phone Number *
Referral IDOC # / MID # *
Risk and Needs Assessment Score (ORAS) *
Referred to the Daily Reporting Center (DRC) for services? *
Referred to the Resource Intervention Center (RIC) for services? *
Referral Area of Concern (Click ALL that Apply!) *
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