SIM Taskforce Referral Form

Agencies receiving Recovery Support Funds through the SIM Taskforce initiative must complete this form. Please provide detailed information when requesting assistance.

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* 1. Referring Agency Name

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* 2. Name of Staff Submitting Referral

Name

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* 3. Has the participant given consent for follow-up contact?

Yes

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* 4. Contact Information for Participant

Name

Company

Address

Address 2

City/Town

ZIP/Postal Code

Phone Number

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* 5. Participants age range:

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 6. Participants gender identity:

Female

Male

Non-binary

Prefer not to say

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* 7. Participants race/ethnicity (Select all that apply):

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Another race

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* 8. Recovery Support Services Need:

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* 9. Check all recovery support services that have been referred for this individual:

Peer support or recovery coaching

Family counseling

Food and nutrition assistance

Housing support services

Employment assistance

Case management

Faith-based support

Vocational training

Education (e.g., GED support)

Family reunification services

Transportation assistance

Assistance with benefits applications

Tribal/Cultural healing

Other (please specify)