Refuge City Referral Form

Refuge City Referral Form
1. Child's Information
Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Phone Number

Area Code Phone Number
Age
2. Parent Info
Name

First Name Last Name
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
3. Referrer
What is your relationship to the child?

Law Enforcement Anti-Trafficking Agency Legal Counsel Social Worker/Case Manager Court Official Family/Friend Other
Name

First Name Last Name
Agency Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
City

City State
What date would the child be available to start in Refuge City's Program?
Day/Month/Year
Check all agencies that are involved in this case.

Law Enforcement Traffick911 CPS Juvenile Justice Child Advocacy Center
Please list the name, phone number and email address for the contact on this case at each agency checked above.
4. Legal
Is the child verified as a victim of...

Trafficking Sexual Exploitation
What is the nature of the trafficking?

Labor Trafficking Sex Trafficking Both
Please give any details you are aware of about the case.
How recently was she/he in a trafficking situation?
specific days/weeks/months
Is the trafficker still a threat?

Yes No
Is there an open or pending case against the trafficker?

Yes No
Is the child a flight risk?

Yes No
5. Health
Is she pregnant?

Yes No N/A
Is the child actively self-injuring?

Yes No N/A
Is the child a suicide risk?

Yes No
Does the child have at least 30 days of sobriety/clean time?

Yes No N/A
Is the child on prescribed pharmacology?

Yes No N/A
Does the child have severe psychiatric issues?

Yes No N/A
Does the child have any immediate health concerns?

Yes No
6. Education
What is the child's last attended grade?
Is the child currently enrolled in school and if so, where?
Is the child interested in furthering their education?

Yes No
Additional Notes:
Should be Empty:

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Refuge City Referral Form

1. Child's Information

2. Parent Info

3. Referrer

4. Legal

5. Health

6. Education