Refuge City Referral Form

Refuge City Referral Form
1. Child's Information
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Phone Number

Area CodePhone Number
Age
2. Parent Info
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

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

Law EnforcementAnti-Trafficking AgencyLegal CounselSocial Worker/Case ManagerCourt OfficialFamily/FriendOther
Name

First NameLast Name
Agency Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
City

CityState
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 EnforcementTraffick911CPSJuvenile JusticeChild Advocacy CenterOther
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...

TraffickingSexual Exploitation
What is the nature of the trafficking?

Labor TraffickingSex TraffickingBoth
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?

YesNo
Is there an open or pending case against the trafficker?

YesNo
Is the child a flight risk?

YesNo
5. Health
Is she pregnant?

YesNoN/A
Is the child actively self-injuring?

YesNoN/A
Is the child a suicide risk?

YesNo
Does the child have at least 30 days of sobriety/clean time?

YesNoN/A
Is the child on prescribed pharmacology?

YesNoN/A
Does the child have severe psychiatric issues?

YesNoN/A
Does the child have any immediate health concerns?

YesNo
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?

YesNo
Additional Notes:
Should be Empty:

Refuge City Referral Form

1. Child's Information

2. Parent Info

3. Referrer

4. Legal

5. Health

6. Education