Referral Form for Outreach Program of Samaritan Works:

Please complete and submit this form for participation in Samaritan Works' Outreach Program: Our Outreach Cooridnator will contact you to set up your first meeting: 

First Name: Client first name       

Last Name: Client last name

Phone nmber: Client phone

Email address: Client email

Current Address: Client Address

                          Client City      Client State     Client Zip

Gender:  Client gender

Why do you want to participate in Samaritan Works' Outreach Program?  Paragraph

Are you willing to keep appointments with our Outreach Coordinator:   Checkboxes

Are you willing to remain sober during your participation with Samaritan Works?  Checkboxes

Are you on Probation?   Checkboxes

Who is your Probation Officer?   Paragraph

Do you consent to Samaritan Works sharing your progress with probation?   Checkboxes

Are you currently in treatment for mental health or SUD?   Checkboxes

IF SO, Where are you receiving treatment?   Paragraph

Please note that your committment to Outreach is key to the success of your participation. You must keep your appointments with our staff, complete assigned projects on time, and remain drug/alcohol free while participating in this program. IF Samaritan Works suspects the use of drugs/alcohol they will report this suspision to probation (if applicable). Samaritan Works reserves the right to cancel their committment to working with you, if you are under the influence of drugs or alcohol, or if you fail to keep your appointments. Our outreach services are free to you.

Signature: Signature