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

FEDERAL 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

Current Location

Current Employment Status

Please specify the employment status

Employer Name

Estimated Monthly Income

Does the participant have a bank account?

Expected Release Date

Supervision Type

Supervising Officer Name

Officer Phone

Officer Email

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

I confirm that the information provided is accurate to the best of my knowledge and that this referral is submitted for consideration in the GriffinHearts Transitional Housing Program.

Referring Officer Name

Agency

Signature

Clear

Date Signed