Reentry Referral Form

Refer a
client

Submit a client referral quickly and securely. We partner with parole offices, jails, courts, shelters, treatment programs, and community organizations across Colorado. Individuals and family members can also self-refer.

Referral Information

Referral date*

Priority*

Is this a new referral or an update?*

Referring Agency & Contact

Referral source*

Agency / organization / facility name*

Your full name*

Title / role

Phone*

Extension / alternate phone

Email*

Secure fax (optional)

Best way to reach you

Best days / times to reach you

Participant Information

Legal last name*

Legal first name*

Middle name / initial

Preferred name

Other names / aliases on record

Date of birth*

Pronouns

Primary language

Interpreter needed?

Participant phone (if any)

Participant email (if any)

Veteran?

How should we contact the participant?

County the participant plans to live in after release

I confirm the participant is an adult man (18+)*

Custody, Identifiers & Release Plan

Current custody status*

Current facility / program name and location

CDOC number

BOP register number

Parole / probation / supervision case number

Other ID (jail booking #, SID, court case #)

Expected (or actual) release date*

Release date is…

Requested admission / move-in date

Next parole board / hearing / review date (if any)

Type of release

Will Fresh Start be the participant's proposed release / residence?

Transportation from the facility needed?

Reporting requirement after release

Supervision & Conditions

Will the participant be (or is he) under supervision?*

Placement Screening

Current or most recent conviction(s) / offense type

Required to register as a sex offender?*

Any arson conviction?

Pending charges, warrants, or detainers?

Previously in a residential / sober-living program?

Special placement considerations

Health, Recovery & Benefits

Substance use treatment or recovery support needed?

Currently on medication for opioid or alcohol use disorder (MOUD/MAT)?

Mental health support needed?

Medical, mobility, or accessibility needs?

Will he leave with prescribed medications?

Health First Colorado (Medicaid) status

Income or benefits at release

Services Requested & Immediate Needs

Primary service requested*

All services requested

Reason for referral / presenting need*

Participant's own goals (in his words, if possible)

Preferred service setting

Check everything he will need in the first 72 hours

Is there an immediate safety concern for the participant or others?

Documents

Documents he will have at release

Signed Release of Information (ROI)

Supervision conditions / parole order

Release plan / reentry plan / case summary

Partner Coordination

Organization

Service provided

Contact name / phone / email

Has this person also been referred to other housing or reentry programs?

Would your agency like status updates on this referral?

Consent, Release of Information & Signature

Is the participant aware of this referral?*

Does the participant agree to be contacted by Fresh Start?*

Release of Information (ROI)*

I certify the information provided is accurate and I have authority to share it with The Fresh Start Center.*

Electronic signature (type your full name)*

Date*

Anything else we should know?

All referral information is kept strictly confidential and used solely for intake and service coordination purposes.

Questions about a referral?

Our intake team is happy to speak with you directly.

(720) 295-6126 Referral@TheFreshStartCenterCo.org

Refer aclient