PLEASE NOTE: Be sure to include your email address and phone number. Please do not include hyphens or periods in phone numbers. If this contact information is not provided, we will not be able to follow up regarding your referral.

Submit Your Own Referral





First Name (required)

Last Name (required)

Date of Birth

SBI Number

Inmate Number

Physical Address

Email (required)

Phone Number – do not use hyphens or periods (required)

Are you currently incarcerated? (required)

If yes, where?

Release date?

Release status: (required)

Requesting to Enroll Client at which NJRC Location: (required)

Requested date of NJRC Service to begin: (required)

Additional Notes

Upload a referral form or other attachment.

Submit a Referral for Someone Else

If you are from an agency, use the “Agency Referral” form.





Your Name (required)

Your Email (required)

Your Phone Number – do not use hyphens or periods (required)

Relationship to Client (mother, friend, former employer, etc.) (required)

Client’s First Name (required)

Client’s Last Name (required)

Client’s Date of Birth

SBI Number

Inmate Number

Client’s Physical Address

Client Email (required)

Client Phone Number – do not use hyphens or periods (required)

Is the client currently incarcerated? (required)

If yes, where?

Release date?

Release status: (required)

Requesting to Enroll Client at which NJRC Location: (required)

Requested date of NJRC Service to begin: (required)

Additional Notes

Upload a referral form or other attachment.

Submit A Referral as an Agency





Your Name (required)

Your Email (required)

Your Phone Number – do not use hyphens or periods (required)

What company, agency, or program are you with?

If “Other,” what agency?

Relationship to Client (Parole Officer, Case Manager, etc.) (required)

Client’s First Name (required)

Client’s Last Name (required)

Client’s Date of Birth (required)

SBI Number (required)

Inmate Number

Client’s Physical Address

Client Email (required)

Client Phone Number – do not use hyphens or periods (required)

Is the client currently incarcerated? (required)

If yes, where?

Release date?

Release status:

Requesting to Enroll Client at which NJRC Location: (required)

Requested date of NJRC Service to begin: (required)

Additional Notes

Upload a referral form or other attachment.

Upload a Referral Form

If you have completed a referral form and want to upload a scan of it, use the form below.





Your Name (required)

Your Email (required)

Your Agency (required)

NJRC Location Referring To (required)

Upload Referral Form (required)