Program Referral Form

Please complete the information below to refer an individual to New Choices.

It will be the participant’s responsibility to contact us by phone at 701-746-0405 or email to schedule an intake appointment.

New Choices Referral

  • REFERRED BY

  • The exchange of information noted on your ROI MUST specific CVIC - NEW CHOICES PROGRAM. A generic CVIC ROI is not valid for the program.
  • Upload a pdf if available.
    Accepted file types: pdf, Max. file size: 50 MB.
  • PARTICIPANT INFORMATION

  • MM slash DD slash YYYY
  • REASON for REFERRAL

  • Please note any current/past use of violence by the individual, or information as to why this individual may benefit from the New Choices program.