Facility Referral to VRN Peer-Based Services ReferralReferral Source*Case ManagerFacility StaffOtherName* First Last Facility Releasing From*--Select Correctional Facility--Chittenden Regional Correctional Facility (CRCF) - South BurlingtonNortheast Correctional Complex (NERCF & CCWC) - St. JohnsburyNorthern State Correctional Facility (NSCF) - NewportNorthwest State Correctional Facility (NWSCF) - SwantonMarble Valley Regional Correctional Facility (MVRCF) - RutlandSouthern State Correctional Facility (SSCF) - SpringfieldOther (describe below)Other/ Comments: In-Facility ContactName* First Last PhoneOK to Leave Voicemail? Yes No Individual Being ReferredName* First Last PhonePhone TypeCellHomeWorkNo Phone - Need a Phone or Other Way to ContactOK to Leave Voicemail? Yes No Residence/ Housing Street Address CitySelect their nearest cityBarreBenningtonBrattleboroBurlingtonMiddleburyMontpelierMorrisvilleNewportRutlandSpringfieldSt. AlbansSt. JohnsburyWhite River JunctionZIP Code (optional) Date of Birth MM slash DD slash YYYY Gender--Select Gender--MaleFemaleNonbinaryOtherProbation & Parole ContactProbation Office*--Select Probation Office--Barre Probation and ParoleBennington Probation and ParoleBrattleboro Probation and ParoleBurlington Probation and ParoleHartford Probation and ParoleMiddlebury Probation and ParoleMorrisville Probation and ParoleNewport Probation and ParoleRutland Probation and ParoleSt. Albans Probation and ParoleSt. Johnsbury Probation and ParoleSpringfield Probation and ParolePhoneName of Probation Officer First Last Alternate Family or Personal Contact: First Last PhoneOK to Leave Voicemail? Yes No Vermont Telephone Recovery Support Service (VTRSS)Permission to Enroll in VTRSS--optional--YesNoI need more information about VTRSS.Start date for peer recovery support calls: MM slash DD slash YYYY CAPTCHA
