Alliance Referral System

Alliance Referral System

Referral Form
We at NTSA are here to help you find residential services for recovery from trafficking or sexual exploitation. This form collects some basic information on your needs and preferences to better help us do that.

By completing this referral form, you are agreeing to allow the National Trafficking Sheltered Alliance to share this information with our referral system network of service providers, for the purpose of finding you appropriate services. This form must be filled out completely before submission. ALL INDIVIDUAL INFORMATION WILL BE KEPT CONFIDENTIAL within the Alliance network. You will be contacted directly by any agency that has availability and is able to consider you for placement. ARS will not replace the assessment process of individual agencies; we are a facilitator only.

We or our partners may publicly share aggregated information such as trends in survivors’ needs when doing so helps us advocate for survivors as a group. We will never publicly share information about individuals.
Date *

Month Day Year
Date
This form can be filled out by yourself or by an advocate representing the individual needing services. Please answer all questions to the best of your ability, and indicate “Not Applicable" (N/A), or provide an alternative answer if necessary. Services are searched for according to the answers given below, so answering honestly will better help us find approproate matches.

DO NOT put identifying information on this application. Please identify the person for whom this referral is being made with the person’s 3 initials and age, for example: AGW21
First Initial:* Middle Initial: Last Initial: *

Age: Number*
Referrer
Who is submitting this referral (select all that apply): *

I am submitting this referral for myself Law Enforcement Safe House or Trafficking Shelter Anti-trafficking Task Force Court Official Social Service Resource Center (non-residential) Friend/Family Member Advocate Other
If you are referring someone else, how long have you known this person?
Number of Days, Months, or Years
Contact

This information will be used by Service Providers to reach you --- if you are referring yourself, please DO NOT INCLUDE YOUR NAME.
Name

First Name Last Name
Agency / Organization Name
Location *

Street Address

Street Address Line 2

City State
Email *
If you are referring yourself, please DO NOT use an email address that identifies you by name
Phone Number *
Please enter a valid phone number.
In what city and state is the individual seeking placement located, if different from above?

Street Address

Street Address Line 2

City State
Information to Facilitate Ideal Placement
Biological Sex *

Female Male Transitioning Male to Female Transitioning Female to Male Other
Are you Transgender? *
Race / Ethnicity (optional)
Are you, or could you be, pregnant? *
If 'Yes', how many weeks into pregnancy do you think you are? *
Number of Weeks (NA if not applicable)
Do you need a program that accepts dependent children? *
If 'Yes', how many children? *
Number of Children (NA if not applicable)
If 'Yes', list the age(s) of the child(ren): *
ex: 3, 6, 7 (NA if not applicable)
*Note: some programs may have a limit on the number and/or age of accompanying children
Preferences
By what date do you need placement? *

Month Day Year
Date
What type of program are you seeking? *

Drop-in/Resource Center (no housing) Emergency Shelter (0-30 days) Short-term Residential Program (90 days or less) Long-term Residential Program (90 days - 2 years) Graduate/Transition Program (independent housing) Undetermined
What level of staff supervision would be most helpful to you? *

Low – live in independent housing and is not at risk of relapse but would benefit from daily or weekly check-ins Moderate – supervision within the housing situation; some off-campus privileges; some boundaries on internet/phone use High – full time staff supervision with restricted phone and internet No preference
How would you like faith to be incorporated into the program, if at all? *

Organization is faith-based with faith-based programming where participation or attendance is required Organization is faith-based with faith-based programming that is optional Organization is faith-based but faith is not incorporated into the programming Organization is secular but has faith-based options available No preference
Do you have any preferences or limitation on where in the United States you should be placed? Please explain: *
Do you require services in a particular language? If so, please specify: *
Services
What type of exploitation are you seeking recovery from? *

Sex Trafficking Labor Trafficking Prostitution Pornography Survival Sex Other forms of commercial sex
How was the trafficking activity verified? *

Individual is a minor; verification not required Trafficking was verified by Law Enforcement or Court Official Individual disclosure Candidate met screening criteria for trafficking Cannot confirm trafficking
If a screening tool was used, please indicate which:
Name of Trafficking Screening Tool
How long ago was your experience with trafficking or exploitation? *
*please indicate the last time you were exploited (not the first occurrence)
Have you previously (or currently) been in a trafficking shelter program? *
If 'Yes', please list:
Legal
Citizenship *
If you're under 18, please specify:

Emancipated Ward of court/state About to age-out Parent/Guardian willing to grant temporary custody Parent/Guardian willing to transfer legal guardianship
Please select all that apply: *

I am actively escaping an abuser I currently have outstanding warrants or legal obligations I am currently involved in an open or pending investigations or cases I will be on parole or probation I am part of a diversion program with court requirements I am currently registered as a sex offender Other
Are you currently incarcerated? *
If 'Yes', what is your anticipated release date?

Month Day Year
Date
Please describe any outstanding warrants or legal obligations that will affect your ability to travel outside the state:
If none, write "NA"
Health
Do you have any immediate health concerns? *
If 'Yes', please describe: *
(NA if not applicable)
Do you need accommodations for any physical disabilities? *
If 'Yes', please describe: *
(NA if not applicable)
Do you ever experience suicidal thoughts? *

Yes No Other
Are you currently taking prescribed medication for mental illness? *
If 'Yes', please list medications and dosage, if known: *
(NA if not applicable)
Have you been diagnosed with a psychiatric /cognitive disorder? *

Yes No Other
If yes, please indicate diagnosis(es):
(NA if not applicable)
Have you recently used illegal substances? *
How recently have you used addictive and/or illegal substances, if applicable? *
Have you ever been in rehab for drug or alcohol abuse recovery? *
If 'Yes', how many times?
Are you in need of addiction recovery services? *

Yes No Other
Comments
Is there anything else we should know?
In signing below, I (survivor) consent to the release of the information above, OR, I (survivor advocate) verify that I have obtained the consent of the individual for whom this referral is being made to release the information above on their behalf. This information may only be shared with the National Trafficking Sheltered Alliance and their participating network of referral receiving agencies for the express purpose of seeking services.

One or both signatures must be included for NTSA to move forward with the referral.

Note: In order to maintain the anonymity of the individual for which this referral is being made, your signature will not be included in the distribution of this information to receiving agencies.
Survivor Signature

Clear
Date

Month Day Year
Date
Survivor Advocate Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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Alliance Referral System

Referrer

Contact

Information to Facilitate Ideal Placement

Preferences

Services

Legal

Health

Comments