Community Partner Referral

Community Partner Referral

Referrals from social service agencies, government agencies, educational institutions, non-profit organizations and community-based organizations.
If the subject of this referral is in immediate danger, please have them contact:

HAVEN’s Crisis Line: 248-334-1274 or 877-922-1274.

TTY C&SL: 248-972-2540
HAVEN Services
Which services are you referring the victim for? Check all that apply.

Court ServicesCounselingCommunity ReferralsOther
Victim Information

All fields marked with an asterick (*) must be completed. Phone or email must be provided for follow-up purposes.
Case #*
Name*

First NameLast Name
Preferred Name

First NameLast Name
Pronouns
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Safe to call?

YesNo
Email
example@example.com
Safe Email?

YesNo
Safe to text?

YesNo
Assailant Name

First NameLast Name
Contact Information
Referred By Name*
Organization
Referral Phone Number*
Referral Email
Additional Information
Charges
Upcoming Hearing
Judge
Court Location
Additional Information
Should be Empty:

HAVEN Services