Treatment Referral Request Form

Instructions: To receive a list of clinicians who provide specialized sexual offender treatment in your geographical area, please complete the form below. Fields in red are required. Information about the offender will help us provide the appropriate referral list. After completing the form, click “Send Referral Form” to submit your request to Safer Society via e-mail. You will be faxed a list of treatment providers whose practice is located in the requested state, usually the next business day. To maintain confidentiality, the offender will be identified only by age and sex on the cover sheet.

If you prefer not to e-mail your request, please click here for the PDF version of this form which you may fax or mail to us.

We can only provide referrals to treatment providers located within the United States.

Safer Society Foundation, Inc. reserves the right to not provide a referral if we believe, in our sole discretion, that the request is being made for any purpose other than to locate a clinician who can provide treatment for a specific individual.

These fields are required

Fax Recipient's Name:
Agency (if applicable):
Requester's State:
Telephone Number:	please be sure to include your area code
Fax Number:	please be sure to include your area code
Type of Treatment:	Outpatient/Community BasedResidential/Inpatient Treatment
Desired Treatment Location (State):
Offender's Sex:	MaleFemale
Offender's Age:
Special Needs:  Developmentally Disabled Spanish Language Services Substance Abuse Major Mental Illness
Enter these in this field: