<p> Connections Corrections Program</p><p>Applicant Information Sheet</p><p>PLEASE TYPE OR PRINT</p><p>THIS FORM IS TO BE COMPLETED BY THE INDIVIDUAL REFERRING AN APPLICANT TO THE CONNECTIONS CORRECTIONS PROGRAM</p><p>Date: ______Applicant’s Name: ______Last First Middle</p><p>AO or SS #: ______Has Applicant been Sentenced? ___Yes ___No</p><p>Present Location of Client: ___MSP ___MASC ___TSCTC ___Jail ___MWP ___BASC</p><p>What is the release destination of this applicant upon successful completion of The Connections Corrections Program?</p><p>___Billings PRC ___Missoula PRC ___Great Falls PRC ___Helena PRC</p><p>___Butte PRC ___Butte WTC ___ISP Location ______</p><p>___Parole Location: ______Conditional Location: ______</p><p>Name and Title of Referring Individual: ______</p><p>Phone Number of Referring Individual: ______</p><p>Signature of Referring Individual: ______Date: ______</p><p>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</p><p>Mail or Fax this Sheet and Application(s) to:</p><p>Connections Corrections Program 111 W. Broadway Butte, MT 59701 Fax: (406) 782-6676</p>