Hackensack :: NJRC

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Bergen County

39 Hudson Street, Suite 404
Hackensack, New Jersey 07601
Phone: 551.256.7897
Fax: 201.604.6973

Facility Director:
Jennifer Peña, 551.256.7889

Contact | Send Referral

Bergen County Resource Guide

Resource Guide

Referral Forms

The following forms will submit to our Hackensack location only. | Choose Different Location

Submit Your Own Referral

First Name Required

Last Name Required

Date of Birth

SBI Number

Inmate Number

Physical Address

Address 1

Address 2

City

State/Province

Country

Postal Code

Email Address Required

Phone Required

Are you currently incarcerated? Required

Yes

No

If yes, where?

Release date?

Release Status Required

Service Location

Requested date of NJRC Service to begin Required

Additional Notes

Upload a referral form or other attachment.

Submit a Referral for Someone Else

Your Name Required

Your Email Required

Your Phone Number Required

Relationship to Client (mother, friend, former employer, etc.) Required

Client’s First Name Required

Client’s Last Name Required

Client’s Date of Birth

SBI Number

Inmate Number

Client’s Physical Address

Address 1

Address 2

City

State/Province

Country

Postal Code

Client Email Required

Client Phone Number Required

Is the client currently incarcerated? Required

Yes

No

If yes, where?

Release date?

Release status Required

Service Location

Requested date of NJRC Service to begin Required

Additional Notes

Upload a referral form or other attachment

Submit A Referral as an Agency

Your Name Required

Your Email Required

Your Phone Number Required

What company, agency, or program are you with?

If “Other,” what agency?

Relationship to Client (Parole Officer, Case Manager, etc.) Required

Client’s First Name Required

Client’s Last Name Required

Client’s Date of Birth Required

SBI Number Required

Inmate Number

Client’s Physical Address

Address 1

Address 2

City

State/Province

Country

Postal Code

Client Email Required

Client Phone Number Required

Is the client currently incarcerated? Required

Yes

No

If yes, where?

Release date?

Release status

Service Location

Requested date of NJRC Service to begin Required

Additional Notes

Upload a referral form or other attachment