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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
2.
Name of Staff Submitting Referral
Name
Email
3.
Has the participant given consent for follow-up contact?
Yes
No
4.
Contact Information for Participant
Name
Company
Address
Address 2
City/Town
ZIP/Postal Code
Phone Number
5.
Participants age range:
Under 18
18-24
25-34
35-44
45-54
55-64
65+
6.
Participants gender identity:
Female
Male
Non-binary
Prefer not to say
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
8.
Recovery Support Services Need:
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)
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