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[{viewVars.title}]
[{br.name}]
Submit
[{viewVars.title}]
Referral Agency Information
Relationship to Client
-- PLEASE SELECT --
[{v}]
[{viewVars.validations.relationship}]
Referral Agency Point of Contact
Referring Agency Name
[{viewVars.validations.agencyName}]
First Name
[{viewVars.validations.agencyFN}]
Last Name
[{viewVars.validations.agencyLN}]
Phone
[{viewVars.validations.agencyPhone}]
Email
[{viewVars.validations.agencyEmail}]
How long have you known the client?
[{viewVars.validations.knowSince}]
Has Client given permission for us to contact them?
-- PLEASE SELECT --
[{v}]
[{viewVars.validations.permission}]
Potential Client Information
Case #
[{viewVars.validations.case}]
First and Last Name
[{viewVars.validations.fullName}]
Date of Birth
[{viewVars.validations.dob}]
Current City
[{viewVars.validations.city}]
State
-- PLEASE SELECT --
[{k}]
Phone
Email
[{viewVars.validations.email}]
Marital Status
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Single
Married
Separated
Divorced
Widowed
Are you a United States Citizen?
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Yes
No
Legal Foreign National
Sexual Identity
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Male
Female
Other
Prefer not to answer
If other, Please give a short explanation:
[{viewVars.validations.otherGender}]
Individual Identifies as a Victim / Survivor of:
-- PLEASE SELECT --
Domestic Sex Trafficking
International Sex Trafficking
Labor Trafficking
Sexual Exploitation
Family Member of a Victim/Survivor
Individual was trafficked:
-- PLEASE SELECT --
As a child
As an adult
Both
Approximate Exit date:
[{viewVars.validations.exitDate}]
Children
How many children does the client have?
[{viewVars.validations.children}]
Names and ages of Children
[{viewVars.validations.childrenDetails}]
Is client currently Pregnant?
-- Please Select --
[{v}]
Potential Due Date
[{viewVars.validations.dueDate}]
Does the Client have child care?
[{viewVars.validations.childCare}]
Are they receiving Child support of any kind? If yes, explain
[{viewVars.validations.childSupport}]
Does client need items or clothing for a baby under the age of 3 years old?
-- Please Select --
[{v}]
Are any of the children enrolled in School?
-- Please Select --
[{v}]
[{viewVars.validations.inSchool}]
Is CPS involved in any way with the client and their children? If yes, please explain.
[{viewVars.validations.CPS}]
Do any of the children have any emotional or physical challenges? If yes, please explain.
[{viewVars.validations.childrenChallenges}]
Housing
What is their current housing situation?
-- Please Select --
[{v}]
Please explain current Housing situation, including names of any residential programs currently residing in.
[{viewVars.validations.housingDetails}]
Is client currently looking for a Residential Program? If so, which kind?
-- Please Select --
[{v}]
Is client currently on a waiting list for housing or residential safe housing?
[{viewVars.validations.waitingList}]
Is client currently in a HUD program?
[{viewVars.validations.HUD}]
Employment
Is the client currently employed?
-- Please Select --
[{v}]
If employed, where
[{viewVars.validations.employedWhere}]
How long have they been employed?
[{viewVars.validations.employedSince}]
If unemployed, is client currently looking for a job?
[{viewVars.validations.lookingForJob}]
Please list any area of interest or experience.
[{viewVars.validations.experience}]
Is client receiving any government funding? If so, what?
[{viewVars.validations.governmentFunding}]
Does client have any transportation?
-- Please Select --
[{v}]
Would client be interested in any of the following? (Check all that apply)
[{empi}]
Education
What is the clients highest level of education
[{viewVars.validations.education}]
Is client currently enrolled in a GED program?
-- Please Select --
[{v}]
Is client currently enrolled in a certification program or college?
-- Please Select --
[{v}]
If yes, please explain where and field of study
[{viewVars.validations.fieldOfStudy}]
Is client interested in any of the following?
-- Please Select --
[{v}]
Does client have access to a computer and the internet?
-- Please Select --
[{v}]
Is the client interested in tutoring services?
-- Please Select --
[{v}]
Physical and Mental Health
Does client currently have any health issues? Please, explain.
[{viewVars.validations.healthIssues}]
Does client have a primary doctor. If so, please list name and contact information
[{viewVars.validations.doctor}]
Does Client have health insurance? If so, please name who with and policy number
[{viewVars.validations.insurance}]
Is client currently taking any medication? If so, please list what medication and what for?
[{viewVars.validations.medication}]
Is client currently seeing a therapist?
-- Please Select --
[{v}]
Has client been diagnosed by a therapist with any mental disorders? If so, please list
[{viewVars.validations.mentalDisorders}]
Is client currently having feelings of hurting themselves or someone else?
-- Please Select --
[{v}]
Is client currently having thoughts about returning back to the life?
-- Please Select --
[{v}]
Is the client currently self harming?
-- Please Select --
[{v}]
Does client have a good support network?
-- Please Select --
[{v}]
Is client open to attending an in person or online Survivor led support group
-- Please Select --
[{v}]
Addiction
Is client currently suffering from an addiction of any kind? (Sex, drugs, alcohol, gambling, etc.)
-- Please Select --
[{v}]
If yes, please explain
[{viewVars.validations.addictionDetails}]
Does client have a current sobriety date? if so, what is it?
[{viewVars.validations.sobrietyDate}]
Does client have a drug of choice? If so, what?
[{pw}]
Is client open to attending NA / AA or any other recovery groups?
-- Please Select --
[{v}]
Does client currently need help with their recovery?
-- Please Select --
[{v}]
If so, is client open to a residential recovery program for addictions?
[{viewVars.validations.recoveryProgram}]
Legal Issues
Does client have any current misdemeanors or felonies on their record? If so, explain when and for what.
[{viewVars.validations.misdemeanors}]
Does client have any current legal representation?
-- Please Select --
[{v}]
Is client looking to have their record expunged?
-- Please Select --
[{v}]
Is client currently on probation or parole?
-- Please Select --
[{v}]
Is the clients Trafficker currently incarcerated?
-- Please Select --
[{v}]
Is there an open or pending case against the clients Trafficker?
-- Please Select --
[{v}]
Is there anything else we should know about any legal issues for this client?
[{viewVars.validations.legalIssues}]
General Economic Empowerment Needs
Does client need essential everyday items for you and/or your family? (Shampoo, soap, toothpaste, deo, etc.)
-- Please Select --
[{v}]
Please list all anti-trafficking and other nonprofits that the client has received services from
[{viewVars.validations.antiTrafficking}]
Does client need access to any of the following? (check all that apply)
[{pw}]
Is there anything else about the client that you think we should know?
[{viewVars.validations.otherNotes}]
Please complete all required fields before submitting
