New Choices Referral

Program Referral Form

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

REFERRED BY
Referrer Name*
First Last
Agency*
Phone*
Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code
Email*
Relationship to Participant
Do you have a signed Release of Information (ROI) from participant?*
The exchange of information noted on your ROI MUST specific CVIC – NEW CHOICES PROGRAM. A generic CVIC ROI is not valid for the program.
- Yes
- No
Upload Signed ROI
Upload a pdf if available.
Accepted file types: pdf, Max. file size: 50 MB.
PARTICIPANT INFORMATION
Name*
First Last
Gender
- Male
- Female
- Other
Birthdate*
MM slash DD slash YYYY
Email
Phone Number
Mailing Address
Street Address City State ZIP Code
REASON for REFERRAL
Briefly describe*
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.
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