Please accurately complete as many of the following questions as possible so that we can provide you with the help you need. This form has safeguards in place to protect your privacy. However because these measures are not HIPAA compliant, Project Courage cannot guarantee the security of your private health information if you submit this form electronically. We check to see if new referrals have been submitted throughout the day, but please give us up to 24 hours to respond. Please do not hesitate to call us directly at 860-388-9656.