Referral Form - Como ROC

Your Name

First

Last

Your Email

Client's Name

First

Last

Client's DOC Number

Sex Offender

How can we help? (Choose no more than 3 of the most important needs)

Recovery Coaching: Provide a Peer Specialist to help and support persons recovery process.
Family: Provide appropriate referrals for parenting and family reunification.
Employment: Provide support to unemployed and underemployed people to improve their situation.
Vocational: Provide options and supports to increase vocational skills.
Housing (Long-term): Assess needs and resources and explore long-term housing options.
Housing (Short-term): Person is currently homeless or living in an unsafe environment.
Basic Needs: Person presently does not have access to food, clothing, hygiene items, or medication
Education: Support individuals’ pursuit of increased education.
Mental Health: Provide and follow up on appropriate referrals to address mental health needs.
Other: Use the message box below.
Trauma Counseling: Provide licensed therapist to address persons trauma.
Drivers License: Person is eligible but needs help overcoming barriers to obtain license.
Case Management: Discuss with a person their needs and connect them to the resources to meet their needs.
Social: Provide opportunities to relationally connect to healthy and productive people.
Substance Use Assessment: Provide DMH approved assessment to identify treatment/recovery needs.
Legal: Consider options for pressing legal situations and explore solutions.
Transportation: Assess needs and explore effective and long-term solutions.

Is the person referred IDEAL to access funding for the following? (Choose only one)

Your Message

What is the total of 9+5?

ROC Parole Officer Online Referral Form