Referral Eligibility.pdf

This is a Referral Eligibility Form used by the South Carolina Department of Probation, Parole and Pardon Services (SCDPPPS) to document and track contractual treatment service participants. The form is designed to record eligibility determinations for approved participants who received services within the prior week. The document contains fields for provider submission information, participant details including name, state identification number, date of birth, assigned agent, county, program assessment date, and projected service end date. The form accommodates up to ten participant entries and requires SCDPPPS signature authorization and completion date.

The form serves an administrative function within the state's probation, parole, and pardon services system, enabling the department to maintain records of service referrals and participant eligibility status through binary eligible/ineligible designations. This documentation is maintained by SCDPPPS for internal use only and supports the state's domestic violence and substance abuse treatment service contracting activities. The form does not specify pricing terms, funding sources, or contract duration, as it functions as an operational tracking document rather than a procurement instrument.