Project Blue Referral Form

Available in Erie and Niagara Counties for adults 18+

Please use the form below to request enrollment in Project Blue.

You may call (716)449-5450 for Erie County referrals or (716)365-9747 for Niagara County referrals or email [email protected] with any questions. If you want to submit a paper copy of your referral form, you can drop it off or mail it to our Community Programs offices at 1001 E. Delavan Ave. #22 Buffalo, NY 14215

Client Name
Date of Birth
Phone Number You Can Be Reached Through
Address
Referral Date
Referral Type
Referring Organization
Referral Contact Name
Referral Contact Phone Number
Referral Contact Email
Number of times Incarcerated
Explain criminal history/current justice involvement
Client Status
Court Dates
What is your current living situation?
Medical Concerns?
If yes, please explain
Are you being treated for mental health?
Are you being treated for substance use?
If not, is the client interested?
Other requested assistance/helpful information
Active Orders of Protection
Emergency Contact
Emergency Contact Phone
Emergency Contact Relation
Alternate Phone
Attorney Contact
Attorney Phone
Attorney Firm
Attorney Email

Project Blue Referral Form

Available in Erie and Niagara Counties for adults 18+

Join Our Newsletter