Referral Eligibility.pdf

This is a Referral Eligibility Form used by the South Carolina Department of Probation, Parole and Pardon Services (SCDPPPS) to track and document contractual treatment service participants. The form is designed to record information for approved participants who received services within the prior week and determine their continued eligibility status. The document captures essential participant data including name, state identification number, date of birth, assigned agent, county of residence, program assessment date, and projected service end date. Each referral entry provides space for eligibility determination, with options to mark participants as either eligible or ineligible for continued services based on compliance and program participation criteria.

The form serves as an internal tracking and administrative tool for the SCDPPPS to monitor contractual treatment services related to domestic violence and substance abuse intervention programs. Providers submit completed forms with participant information, and SCDPPPS staff signatures and dates are required for official documentation and record-keeping purposes. The form accommodates up to ten participant entries per submission period and functions as part of the agency's broader case management and referral system for individuals under probation, parole, and pardon supervision requiring treatment services.