Referral Form Leave this field blank Youth Information Date of Referral Youth’s Name (First & Last) Date of Birth Age at Referral (optional) Contact # (optional) Youth’s Address (optional) Zip Code Race/Ethnicity (optional) Gender Identification (optional) Female Male Non Binary Other Pronouns (optional) They/Them She/Her He/Him Language(s) spoken at home (optional) Emergency Contact (First & Last) (optional) Contact # (optional) Relationship (optional) Referral Source Information Referring Person Name (First & Last): Contact # Agency or Relationship to youth Email Does the youth know the referral has been made? (optional) Yes No Is this a re-referral? Yes No Youth’s current living situation ChooseEmergency Shelter (including Hotel or motel voucher paid for by an agency)Family or FriendFoster care home or group homeJail, prison, or Juvenile Justice Detention CenterRoom, apartment or house you rentPsychiatric hospitalTransitional housingCouch-surfingHotel or motel (without voucher support)Other (car, park, street, etc.) Referral reason Has the youth disclosed: (Mark all that apply) (optional) Being currently exploited? Yes No A history of exploitation? Yes No Being closely impacted by trafficking? (Friends or family previously or currently being exploited or exploiting others.) Yes No Labor Trafficking? Yes No Suicidality? Yes No Homelessness? Yes No Having a significantly older partner(s)? Yes No Frequent housing/placement disruptions? Yes No Involvement in foster care? Yes No Involvement in the criminal justice system? Yes No Having to exchange sex to meet their basic needs? (food, shelter, money, etc.) Yes No Having been asked, forced, or intimidated to have sex with another person? Yes No Case Management Service Goals Mark all that apply: (optional) CSEC Education Health & Wellness Basic Needs Support Employment Money Management Placement Stabilization Support Education Access to Supportive Community of Peers Other Reason for the referral (optional) (Please provide us with information regarding why the youth is being referred to receive CSEC specific services, be sure to include any safety concerns you may have.) Send
