CIT Referral Form

Please complete the form below. Staff will follow up on your referral the next business day. If you need immediate assistance, please call crisis staff at (330) 725-9195. Thank you.

*Security Key:

*Officer Name:

*Police Department:

Phone Number:

*Client Name:

Client Date of Birth:

*Gender:

*Race:

Client Phone Number:

Client Address:

*Primary Reason for Referral:

Please describe the reason for the referral:

*Charges Filed:

Outcome of your involvement: