Take the first step toward recovery and rebuilding your life. Complete the form below to request our services.
PLACEHOLDER / NEEDS CLIENT INPUT: Referral form goes here — build with Gravity Forms per the technical build plan (not included in this import; forms are built directly in the form-builder plugin, not imported as page content).
Referral Information
- Agency/Organization *
- Contact Name *
- Phone *
- Email *
Participant Information
- Full Name *
- Date of Birth *
- Phone *
- Emergency Contact Name
- Emergency Contact Phone
Services Needed
- Recovery Mentoring
- Recovery-Focused Reentry Support
- Transportation Assistance
- Workforce Development
- Accountability & Stabilization
- Community Resource Coordination
- Case Management
Participant Barriers/Needs
- Employment
- Housing
- Mental Health
- Substance Use Recovery
- Education
- Childcare
- Legal Issues
- Lack of Support System
- Family Issues
Employment Status
- Employed
- Unemployed
- Student
- Retired
- Unable to Work
Additional Information
Notes or Additional Details (open text field)
Need Immediate Assistance?
If you need to speak with someone right away, please call us.
Call Now: 765-241-3798 | Email: rcrrservices@gmail.com
PLACEHOLDER / NEEDS CLIENT INPUT: This form collects sensitive info (DOB, mental health/substance-use flags, emergency contacts). Add a short consent/privacy line above the submit button.