Referral for Services

Referral for Services
Participants Information:
Full Name: *
First Middle Last
Date: *

Month Day Year
Date
Address *

Address

Street Address Line 2

City State

Zip
Cell Phone #: *
Alternate Phone #: *
State Id #: *
Gender: *

Male Female
Driver License #: *
Date of Birth: *

Month Day Year
Date
Age: *
Race: *
Is BIPP court ordered? *

Yes - Please include Court documents No
Do you have an open CPS Case? *

Yes No
Are you on Probation? *

Yes No
Probation/Parole Officer's Name: *
Contact Phone #: *
Length of Supervision: *
Reason for Probation: *
Referred by Details:

Who sent you to BIPP services?
Agency: *
Name: *
Contact Number: *
Email: (this will be used for updates on progress) *
example@example.com
Justification: (Explain why this person belongs in our BIPP Program) *
STAR Council offers BIPP in the following locations. Each referral will be reviewed by the BIPP Coordinator, who will contact the individual to schedule the intake appointment.

Stephenville, TX

Cleburne, TX

Mineral Wells, TX
Please return the completed referral sheet, with any supporting documentation, to the referral department by clicking the submit button below, or email to bipp@starcouncil.org.

We thank you for your time and assistance, it is appreciated. If you have questions or concerns, please do not hesitate to contact us at (254) 965-5515.
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