MAKE A REFERRAL | Wake LRC

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ABOUT
MAKE A REFERRAL
JOIN THE LRC
OUR WORK

Use tab to navigate through the menu items.

** Individuals must be 18 years old and either a Wake County resident, former resident, or their most recent conviction was in Wake County.

REFERRAL FORM

Facility Staff:

Please email the NCDPS Official Transition Documents to WakeLRC@wakegov.com.

Release/Projected Release Date

Client Information

First Name

Last Name

Age

Date of Birth

Gender

Race

Race, if other.

Most recent home address

City, State

Zipcode

Email

Phone

Primary Language

Interpreter needed?

If yes, language or ASL

Computer assistance needed?

Veteran?

MH/SA Diagnosis

Medications

Name of treatment center (Ex. Monarch, Southlight, etc.)

©2023 Capital Area Workforce Development

Equal Opportunity Employer/Program

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