Connections Corrections Program
Application Information Sheet
PLEASE 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
Go to the Application for Admission Form
or