RISE Peer Recovery: Recovering Individuals Supporting Everyone
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REFER SOMEONE FOR SERVICES

Connect someone to support

A certified peer coach from the county you select will reach out within one business day. Every referral stays confidential.

HOPE IN CRISIS

If you or someone you love is in immediate danger, please call 9-1-1 or the 988 Suicide & Crisis Lifeline.

Please do not include private health information on this form.

Client First name *
Client Last name *
Email *
Referred by:  (Name and Title, list 'Self' if you are referring yourself) *
Date of Birth *
Gender *
Contact number *
Address *
County of Residence *
What is the best time for us to return your call? *
Are you currently on Probation, Parole, or Community Correction Supervision? *
If yes to the previous question, who is your case manager or probation officer?  *
Do you currently have insurance? *
Please provide a summary of why you are seeking services *

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