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PARTICIPANT INTEREST & REFERRAL

Get Started with Willowcrest

Average completion time: 3–5 minutes.

Complete this confidential form if you are interested in Willowcrest for yourself or are referring someone who may benefit from our premium recovery housing and individualized stabilization services. Our team will review program fit, individual needs, funding options, and availability, then contact the participant and/or referring party to discuss next steps.

RECOVERY HOUSING • COORDINATION • REENTRY SERVICES • STABILIZATION

Information submitted through this secure form is reviewed only by authorized Willowcrest staff and is used solely to evaluate placement and coordinate services.

CONFIDENTIAL INTEREST & REFERRAL FORM

Begin Your Willowcrest Inquiry

Please provide the information below to help our team evaluate program fit, support needs, and appropriate next steps. This form may be completed by an individual seeking services or by someone referring an individual to Willowcrest. Fields marked with an * are required.

REFERRAL SOURCE INFORMATION
PARTICIPANT INFORMATION
Date of Birth
Month
Day
Year
Gender
Current Living Situation
Requested Admission / Placement Date
Month
Day
Year
How urgent is this placement?
Immediate / Same Day
Within 24–48 Hours
Within 3–7 Days
More Than 7 Days
Flexible / To Be Determined
PLACEMENT & SUPPORT NEEDS
Primary Reason(s) for Referral
Participant is being referred from:
Is the participant seeking a substance-free, recovery-supportive living environment?
Yes
No
Unsure / Needs Assessment
What areas of support may the participant need?
Requested Willowcrest Service Level
Level 1 — Premium Recovery Housing
Level 2 — Recovery Coordination
Level 3 — Recovery & Reentry
Level 4 — Comprehensive Support
Level 5 — Enhanced Housing Stabilization
Not Sure — Please Recommend the Appropriate Level
PLACEMENT SCREENING
Does the participant currently require detoxification, withdrawal management, or 24-hour medical supervision?
Yes
No
Unsure
Are there any known immediate safety, behavioral, legal, or placement concerns that Willowcrest should review before admission?
Yes
No
Unsure
Does the participant have any accessibility, mobility, or accommodation needs that may affect housing placement?
Yes
No
Unsure
FUNDING & REFERRAL CONFIRMATION
Anticipated Funding Source
Referring Agency / Organization
County or Government Program
Healthcare / Behavioral Health Organization
Insurance / Managed Care Organization
Veterans Program
Grant or Community-Based Program
Self-Pay
Family / Private Pay
Other
Unknown / To Be Determined
Has funding or payment authorization been confirmed?
Yes — Funding Authorized
Pending Authorization
No — Funding Not Yet Authorized
Not Applicable / Self-Pay
Unsure
Is your organization interested in establishing or expanding a referral partnership with Willowcrest?
Yes
Possibly — Please Contact Me
We Already Have an Established Partnership
No / Not Applicable
Referral Confirmation

Submission of this referral does not guarantee admission or placement. Willowcrest will review the information provided, assess program fit and availability, and contact the referring party regarding next steps.

Please provide information regarding the individual being referred for placement.

Help us understand the participant's current needs and the services requested.

STEP 1

STEP 2

STEP 3

STEP 4

STEP 5

STEP 6

Provide funding information and review the referral before submission.

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