Connections Corrections Program

Applicant Information Sheet

PLEASE TYPE OR PRINT

THIS FORM IS TO BE COMPLETED BY THE INDIVIDUAL REFERRING AN APPLICANT TO THE CONNECTIONS CORRECTIONS PROGRAM

Date: ______Applicant’s Name: ______Last First Middle

AO or SS #: ______Has Applicant been Sentenced? ___Yes ___No

Present Location of Client: ___MSP ___MASC ___TSCTC ___Jail ___MWP ___BASC

What is the release destination of this applicant upon successful completion of The Connections Corrections Program?

___Billings PRC ___Missoula PRC ___Great Falls PRC ___Helena PRC

___Butte PRC ___Butte WTC ___ISP Location ______

___Parole Location: ______Conditional Location: ______

Name and Title of Referring Individual: ______

Phone Number of Referring Individual: ______

Signature of Referring Individual: ______Date: ______

Please review application for accuracy prior to submitting it to Connections Please include any of the following items that are available:  Judgment and Commitment Papers  Initial Parole Board Report and Disposition  Reports of Violation  Current Medical Release from MSP, WSP, BASC, or MASC  Montana Mental Health Services Plan Application (if applicable)  PSI Report  Psychological Evaluation or Reports  Any Discharge Summaries from past treatment episodes  Initial Classification Summary and Report  Summary of Unit Performance

Mail or Fax this Sheet and Application(s) to:

Connections Corrections Program 111 W. Broadway Butte, MT 59701 Fax: (406) 782-6676