Project Courage Referral Form |
Part 1: General Info
Please accurately complete as many of the following questions as possible so that we can provide you with the help you need. This form has administrative, physical and technical safeguards in place that are consistent with HIPAA requirements to protect privacy. We check to see if new referrals have been submitted throughout the day, but please give us up to 24 hours to respond. Please do not hesitate to call us directly at 860-388-9656.