Serving South New Jersey

Professional and Community Referrals

Restore Village Recovery Housing welcomes referrals from treatment providers, hospitals, courts, community organizations, and families across South New Jersey.

Who Refers to Us

Detoxification programs
Residential treatment centers
Outpatient treatment providers
Hospitals
Behavioral health programs
Therapists
Social workers
Case managers
Courts
Probation and parole professionals
Reentry programs
Community organizations
Faith-based organizations
Families and loved ones

Submit a Referral

Referring Professional

Referring professional's name *

Professional title

Organization

Work email *

Direct phone number *

Applicant Information

Applicant's full name *

Preferred name

Date of birth

Applicant phone number

Applicant email address

Current location

Anticipated discharge date

Expected move-in date

Clinical and Support Details

Current level of care

Recommended level of housing support

Sobriety date, if applicable

Substance or substances of concern

Is detoxification currently needed?

Is the applicant medically stable?

Does the applicant require mobility accommodations?

Does the applicant have health insurance?

Current medications

Known behavioral or medical concerns

Legal or supervision requirements

Financial or funding source

Secure Document Upload

Upload discharge summary

PDF, DOC, or image. Max 10 MB.

Upload identification

PDF, DOC, or image. Max 10 MB.

Upload medication list

PDF, DOC, or image. Max 10 MB.

Upload referral documents

PDF, DOC, or image. Max 10 MB.

Needs and Goals

Brief description of housing needs

Brief description of recovery goals

Any safety, medical, behavioral, accessibility, or support needs we should know about

Emergency contact name

Emergency contact phone number

Preferred contact method *

I confirm I have appropriate authorization to communicate about this individual and to share the information submitted with Restore Village Recovery Housing.I consent to being contacted about this referral and confirm the information provided is accurate to the best of my knowledge.I acknowledge the Privacy Policy and understand that sensitive health information should only be shared through approved secure channels.

Submitting this form does not guarantee admission. Restore Village Recovery Housing will review the information provided and contact the applicant or referral source regarding next steps.