Aligning a new opportunity with our core mission

Our referral process ensures that participants are pre-screened and properly aligned with our structured programs.

Complete the form below with accurate information about the individual you are referring.

Please ensure your referral meets the program criteria:

✔ Individual is ready for structured housing and routines

✔ Open to case management and behavioral support

✔ Committed to personal development

✔ Suitable for partner programs if recommended

REFERRAL FORM

(For Probation Officers, Case Managers, Reentry Agencies, Courts, and Federal Partners)

Program Overview:

GriffinHearts Transitional Housing provides structured housing and reintegration support for Returning Citizens transitioning from incarceration to stable community living. The program emphasizes accountability, employment, financial responsibility, and successful reintegration.

REFERRING AGENCY INFORMATION

Agency Name *

Agency Address *

Referring Officer / Case Manager Name *

Title / Position

Phone *

Email *

Type of Referral

Please specify other type of referral

By submitting, you authorize GriffinHearts LLC to text/call the number above for informational/transactional messages, possibly using automated means. Msg/data rates apply, msg frequency varies. Consent is not a condition of purchase. See terms and privacy policy Text HELP for help and STOP to unsubscribe.

REFERRED APPLICANT INFORMATION

Full Legal Name *

Date of Birth

Phone Number *

Email Address

Expected Release Date

Supervising Officer Name

Officer Phone

Officer Email

SUPERVISION & LEGAL REQUIREMENTS

Please provide any available supervision or legal supervision information for the referred individual.

FEDERAL PROBATION INFORMATION

Federal Probation District:

Assigned Probation Officer (if known):

Probation Officer Contact Information (if available):

SUPERVISION STATUS

Type of supervision:

Please provide other type of supervision

Will the participant be on any form of supervision upon release?

RESTRICTIONS & CONDITIONS

Are there any curfew restrictions?

If yes, please explain the curfew restrictions:

Are there any travel restrictions?

If yes, please explain the travel restrictions:

Are there any special supervision conditions we should be aware of?

If yes, please explain the special supervision conditions:

Are there any housing-related restrictions or placement limitations?

If yes, please explain the housing-related restrictions or placement limitations

Are there any sex offender restrictions or registry requirements applicable to placement consideration?

If yes, please provide any relevant placement considerations:

ADDITIONAL INFORMATION FOR PLACEMENT REVIEW

Please provide any additional legal, supervision, or compliance-related information GriffinHearts should be aware of prior to placement review:

INCOME & FINANCIAL STABILITY

Please provide information regarding the participant’s income sources and financial stability.

Type of income currently received:

Please specify the income status

Employer Name

Estimated Monthly Income

Does the participant have a bank account?

Does the participant currently receive any disability income?

Will the participant require financial assistance upon release?

Is there a sponsor, family member, or organization assisting with initial housing/program fees?

If yes, please provide details about the initial housing/program fees:

TRANSPORTATION & ARRIVAL PLANNING

Please provide transportation and arrival information for the participant’s transition to GriffinHearts Transitional Housing.

Who will be transporting the participant?

Estimated arrival date:

Estimated arrival time:

Does the participant require transportation assistance upon release?

Will the participant be arriving directly to GriffinHearts housing?

Has transportation to the GriffinHearts location been confirmed?

Are there any travel-related concerns, delays, or barriers we should be aware of?

Program Fit Rating Matrix

Rate the Applicant

5-star (highest) 1- star (lowest)

Accountability

Rule Compliance

Motivation

Emotional Regulation

Participation Readiness

Program Fit Assessment

Program Suitability Recommendation

Strong Fit for Structured Program

Moderate Fit (Needs Support & Monitoring)

Limited Fit (Conditional Placement Only)

Not Suitable for Program Structure

Conditional Placement Factors

Additional Notes

Provide any additional relevant information regarding the participant’s background, needs, or risks:

Referral Certification

Referring Officer Name

Agency

Signature

Clear

Date Signed

Confidential • Professional Review • Structured Process

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Contact:

+1 980-998-2985
[email protected]

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