Referring Agency
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Agency Contact
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First Name
Last Name
Agency Contact Email
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Agency Contact Phone
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Should we contact you first before reaching out to the client?
Client Name
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First Name
Last Name
Client's Age
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Client Race
Client Contact Info
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Do we have permission to contact the client directly?
Where is she located?
If other or out of state, please explain.
What is her current living situation?
Does she have her own means of transportation?
Please provide a brief description of her trafficking history.
Did the most recent instance of exploitation take place within the past 45 days?
Is law enforcement involved?
Can you explain their involvement?
What is her relationship to her trafficker?
Is her trafficker in custody?
If no, Is that is something she is interested in working towards?
Is the client in need of immediate shelter?
Does the client have children?
Is yes, how many? And what are their ages and genders?
If so, are her children in their custody?
Is she currently pregnant?
Can you explain her mental health background?
Does she have any medical needs?
Can you explain her drug history?
Does she have a criminal history? If so, please explain.
Is she currently on probation?
Are there any safety measures our staff should be made aware of?
Briefly explain what makes you believe this client will be a good fit for our program.
What services is she interested in?
Please check all that apply.
What is your agency's involvement?
Please specify if that will change if she begins receiving our services.
Is there anyone else involved in her care that we should know about?
Homeland Security, safe friends or family, CPS caseworkers, detectives, shelter staff, etc.
If there is any additional information about the client or her situation that is important for us to know, please include that here.
