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Referral Form

Basic Info

First Name *

Last Name *

Email *

Phone *

Relationship to Person Being Referred

Family Member
Friend
Case Worker
Probation / Parole
Employer
Community Member
Other
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Person You Are Referring

Full Name
Phone Number
Email (if known)

Age Range:

18–24

25–34

35–44

45+

What support is needed?

Housing assistance

Employment support

Transportation

Identification documents

Mental health support

Substance recovery

Life skills coaching

Re-entry planning

Emergency stabilization

Not sure / needs assessment

Current Situation (Optional but helpful)

Is the person currently incarcerated?

Yes

Recently released?

Yes

Is this an urgent situation?

Yes

Consent / Awareness

I confirm the person being referred is aware or would benefit from being contacted.

By checking this box, I Consent to Receive SMS Notifications, Alerts, and follow up SMS from Closing Circles Inc. Message frequency may vary. Message & data rates may apply. Text HELP for assistance. You can reply STOP to unsubscribe at any time.

By checking this box, I Consent to Receive the Occasional Marketing Messages from Closing Circles. You Can Reply Stop to unsubscribe at any time.

Let’s Work Together

Whether you’re a business, nonprofit, service provider, or community organization, partnering with Closing Circles helps create real pathways to stability and success.

We’re always looking for mission-aligned partners ready to make a difference.