Program Referral Form

Who may qualify for this program?

• Individuals referred from:

  • DCS

  • Adult Probation

  • Juvenile Probation

  • Court-orders

  • Other community referring agencies

Who may not qualify for this program?

• Individuals with a diagnosed sexually-related disorder

• Individuals with a rape/assault charge

• Individuals with a felony charge

• Individuals who previously were unsuccessful in completing this program

• Other reasons at discretion of provider

If any of the above criteria apply, the client should not be referred. Please contact RETA with questions.

*When referring a client, please attach all related documentation here, including but not limited to: police reports, court orders, probation documents, etc.