Referral Form - Reentry Opportunity Center

ROC Parole Officer Online Referral Form

Your Name *

First

Last

Your Email *

Your Phone Number *

Client's Name *

First

Last

Client's Phone Number *

Client's Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Client's DOC Number *

Client's Date of Birth *

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? *

Visit Us

Address: 2108 Paris Rd Columbia, MO 65202

Phone: 573.607.9372

Email: christopher@comoroc.org

Office Hours: Monday – Friday 9:00 am – 4:00 pm

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