Referral Form

Note to the Reference:

We appreciate all candid and relevant information you provide. Your feedback will be used in conjunction with other information to determine the applicant's readiness and appropriateness for participation in the CU Collegiate Recovery Community.

The CUCRC community is a peer-led recovery support community. Please appraise this applicant's readiness for both maintaining their personal sobriety and actively participating in a recovery-focused community in your response. Please note, we prefer a minimum of three to six months of continuous abstinence by the date in which they join the CUCRC community. Thank you for your assistance and information.

A staff member may contact you for clarification on the information you provided if necessary. Please contact cucrc@colorado.edu or 303-492-9642 with any questions.

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Applicant Information

This information is about the applicant. A referring individual should not fill out this form without consent of the applicant they are referring.

Applicant First Name

Middle Name

Last Name

Release of Information

Yes

Have you received consent from the applicant to provide answers to the following questions? By agreeing you are stating the applicant has consented to the release of information necessary for the CU Collegiate Recovery Center staff to determine my appropriateness/readiness for the CORE Community.

Reference First Name

Reference Middle Name

Reference Last Name

Street Address

Apartment/Unit Number

City

State

Phone Number

Email Address

What is your relationship to the applicant?

Dates providing services to the individual

Why do you believe this applicant is ready to participate in a recovery-focused community in terms of cognitive abilities, thought processes, strengths, deficits, vocational or academic progress?

Please provide a couple of concrete examples, if possible.

What leads you to believe this applicant is working a healthy recovery/sobriety program?

Please provide specific information regarding well-being practices, meeting or support group attendance, sponsor or mentor relationship, spiritual connection, amount of time clean/sober/abstinent, etc.

What are the potential challenges this applicant may face in their ability to succeed in this community and their academics while maintaining well-being and sobriety/recovery?

What coexisting issues, addictions or behaviors are present with this individual? What information do you have about them and what are your concerns?

What health concerns do you have in regards to daily hygiene, physical fitness and nutrition—including the use of caffeine, nicotine and energy drinks?

How would you describe this individual’s emotional health/sobriety in terms of stress, mood, energy, sleep, coping and communication skills? To the best of your knowledge, do they take medications as prescribed and attend scheduled therapy/psychiatric medication appointments? Any concerns?

What information can you provide regarding their current relationships with peers, parents and significant others?

Are there any legal issues either past or present that you are aware of? If so, what?

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Referral Form