Survivor Advocacy Referral Form
Referred By Contact Information
Referred By Contact Information
Referral Date
*
-
Month
-
Day
Year
Date
Referred By Name
*
First Name
Last Name
County/Parish
*
Please Select
Brazos
Burleson
Robertson
Madison
Grimes
Washington
Leon
Walker
Denton
Johnson
Tarrant
Parker
Hood
Somervell
Erath
Wise
McLennan
Falls
Freestone
Hill
Limestone
Bosque
Smith
Bell
Harris
Brazoria
Galveston
Fort Bend
Matagorda
Bastrop
Lee
Travis
Williamson
Hayes
Fayette
Orleans Parish
Jefferson Parish
Plaquemines Parish
St. Bernard Parish
East Baton Rouge Parish
West Baton Rouge Parish
East Feliciana Parish
West Feliciana Parish
Iberville Parish
Point Coupee Parish
Referred By Agency/Organization - Austin Area
*
Please Select
Austin Police Department
Bastrop County Probation
Center for Child Protection
Children’s Advocacy Center (Bastrop)
Children’s Advocacy Center (Lee)
Children’s Advocacy Center (Fayette)
Dell Children's Medical Center
Dell Seton Hospital
Department of Public Safety (DPS)
Gardner Bets Juvenile Detention
Good Samaritan
Hays County Probation
Human Trafficking Division - OAG
Pflugerville Police Department
Round Rock Fire Department
Round Rock Police Department
TXDFPS
U.S. Committee for Refugees and Immigrants
Other
Other Referred By Agency/Organization - Austin Area
*
Referred By Agency/Organization - BCS Area
*
Please Select
Baylor Scott & White Medical Center (College Station)
Bluebonnet Haven
Brazos County Juvenile Detention Center
DFPS
Home of Hope
MHMR Authority of Brazos County
Scotty's House Brazos Valley Child Advocacy Center
Sexual Assault Resource Center (Brazos Valley)
Texas Office of Attorney General
Unlimited Potential (Brazos Valley)
Other
Other Referred By Agency/Organization - BCS Area
Referred By Agency/Organization - East Texas Area
*
Please Select
CPI
Juvenile Probation
Morningside Juvenile Detention Center
Smith County CAC
Smith County District Attorney's Office
Smith County Sheriff's Office
Tyler Police Department
Other
Other Referred By Agency/Organization - East Texas Area
Referred By Agency/Organization - Houston Area
*
Please Select
Advocacy Center for Children of Galveston County
Alvin Police Department
BCFS Common Thread
Brazoria County Alliance for Children
Brazoria County JJC
DFPS
Dickinson Police Department
Elijah Rising
FBI
Galveston County District Attorney's Office
Galveston County JJC
Galveston Police Department
Harris County District Attorney's Office
Houston Police Department
Human Trafficking Rescue Alliance (HTRA)
La Marque Police Department
Memorial Hermann Hospital
Rescue America
Texas Department of Public Safety (DPS)
Texas Forensic Nurse Examiners
The Landing
TRIAD (Harris County Care Coordinator)
United Against Human Trafficking (Pathway Network)
University of Texas Medical Branch (UTMB) Hospital
YMCA
Other
Other Referred By Agency/Organization - Houston Area
Referred By Agency/Organization - North Texas Area
*
Please Select
ACH Child and Family Services
Alliance for Children
Arlington Police Department
CASA of Denton County
CASA of Tarrant County
Childrens Advocacy Center of Johnson County
Childrens Advocacy Center for North Texas
Cook Childrens Hospital
Denton County Juvenile Detention Center
DFPS - Conservatorship
DFPS - CPI
DFPS - FBSS
Fort Worth Police Department
Fort Worth Pregnancy Center (76110)
JPS Hospital
Lynn W. Ross Juvenile Detention Center (Tarrant County)
MHMR of Tarrant County
National Human Trafficking Hotline
One Safe Place
Our Community Our Kids (OCOK)
Texas Health Behavioral Health Center Southwest Fort Worth
Texas Health Harris Methodist Hospital Fort Worth
Tarrant County District Attorneys Office
Tarrant County Sheriffs Office
Underground drop-in center
Other
Other Referred By Agency/Organization - North Texas Area
Referred By Agency/Organization - Waco Area
*
Please Select
Advocacy Center for Crime Victims and Children
American Gateways
Ascension Providence
Baylor Scott & White
Behavioral Health Network (formerly MHMR)
Bellmead Police Department
Bill Logue Juvenile Justice Center
Central Texas Youth Services
Chase House
DFPS
Dobey Center
Family Abuse Center
Killeen Police Department
Lacy Lakeview Police Department
McLennan County Sheriff’s Office
National Human Trafficking Hotline
Safe Alliance
Temple Police Department
The Cove
Trinity Home
Waco ISD
Waco Police Department
Other
Other Referred by Agency/Organization - Waco Area
Referred By Agency/Organization - Baton Rouge Area
*
Please Select
Baton Rouge Child Advocacy Center
Baton Rouge Police Department
Capital Area CASA
Capital Area Family Justice Center
East Feliciana Parish Sherrif's Office
Louisiana Alliance for Child Advocacy Centers
Louisiana State Police
Louisiana Department of Public Safety and Corrections
State of Louisiana DCFS
West Baton Rouge Sheriff's Office
West Feliciana Sheriff's Office
Other
Other Referred by Agency/Organization - Baton Rouge Area
Referred By Agency/Organization - New Orleans Area
*
Please Select
Children's Hospital New Orleans
Jefferson Parish Sheriff's Office
Jefferson Children's Advocacy Center
Lousiana Alliance for Child Advocacy Centers
Louisiana Center for Children's Rights
New Orleans Child Advocacy Center
New Orleans Family Justice Center
New Orleans Sheriff's Office
New Orleans Police Department
Orleans Parish Sheriff's Office
State of Louisiana DCFS
Other
Other Referred by Agency/Organization - New Orleans Area
Office Phone
*
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
*
example@example.com
Client Referral Information - Trafficking Assessment
Client Referral Information - Trafficking Assessment
Type of Trafficking
*
Please Select
Sex
Labor
Both Sex and Labor
Classification
Potential victim of human trafficking
Confirmed trafficking
Clear Concern by CSE-IT
CSE-IT Score
Date CSE-IT was completed
-
Month
-
Day
Year
Date
CSE-IT Upload
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Client Demographics
Client Demographics
Client First Name
First
Client Last Name
Last
Legal Name (if different from Client Name) First
First
Legal Name (if different from Client Name) Last
Last
Date of Birth
-
Month
-
Day
Year
Date
Age
Client 18+ Email
example@example.com
Client 18+ Phone Number
Please enter a valid phone number.
Client Address
Address Line 2
Client Address - City
Client Address - State
Client Address - Zip
5 digit zip code
Race
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian and Other Pacific Islander
White Non-Latino/Caucasian
Other Race
Race - Other
Ethnicity
Non-Hispanic/Non-Latin(a)(o)(x)
Hispanic/Latin(a)(o)(x)
Country of Citizenship
Please Select
United States of America
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Congo-Brazzaville)
Costa Rica
Croatia
Cuba
Cyprus
Czechia (Czech Republic)
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (fmr. ""Swaziland"")
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (formerly Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestine State
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Gender
Male
Female
Other
Not Reported
Trans Female (MTF or Male to Female)
Trans Male (FTM or Female to Male)
Gender Non-Conforming (i.e. not exclusively male or female)
Gender - Other
Pronouns
he/him/his
she/her/hers
they/them/theirs
Pronouns - Other
Current Placement/Location
Projected Length of Placement/Detainment
Legal Guardian Information
Legal Guardian Information
Legal Guardian First Name
Legal Guardian Last Name
Legal Guardian Phone
Please enter a valid phone number.
Legal Guardian Email
example@example.com
Legal Guardian Address
Legal Guardian Address 2
Legal Guardian City
Legal Guardian State
Legal Guardian Zip
Legal Guardian's Primary Language
Please Select
Arabic
Chinese
Mandarin
English
Filipino
French
Korean
Russian
Spanish
Swahili
Vietnamese
Client Contacts
Client Contacts
Probation Officer
No
Yes
Investigating LE Contact(s)
No
Yes
Attorney
No
Yes
Therapist
No
Yes
Probation Officer (PO)
Probation Officer (PO)
PO First Name
PO Last Name
PO - Phone
Please enter a valid phone number.
PO - Email
example@example.com
Investigating LE Contact(s)
Investigating LE Contact(s)
Investigating LE First Name
Investigating LE Last Name
Investigating LE Contact(s) - Phone
Please enter a valid phone number.
Investigating LE Contact(s) - Email
example@example.com
Attorney
Attorney
Attorney First Name
Attorney Last Name
Attorney - Phone
Please enter a valid phone number.
Attorney - Email
example@example.com
Therapist
Therapist
Therapist First Name
Therapist Last Name
Therapist - Phone
Please enter a valid phone number.
Therapist - Email
example@example.com
Referral History
Referral History
Relevant History
(e.g. youth’s reported history of abuse/exploitation/trafficking, etc.)
Currently Enrolled in School
No
Yes
Last Grade Completed
Please Select
Less than High School
Some High School
High School Graduate/GED
Technical School Graduate
Attended College
College Graduate
Master's Degree
Unknown
Name of School, City
ISD
Education notes
Does this client have children?
No
Yes
If "Yes", do they have custody?
No
Yes
Child Protective Services Involvement
Child Protective Services Involvement
Current Child Protective Service Status
No Child Protective Service involvement
Child Protective Service Investigation (CPI)
Child Protective Services supportive services to family, not in state custody (FBSS)
State Conservatorship/ Foster Care
Extended Foster Care (18+)
CPS Person ID
Child Protective Service Investigator First Name
Child Protective Service Investigator Last Name
Child Protective Service Investigator Office Phone
Please enter a valid phone number.
Child Protective Service Investigator Cell Phone
Please enter a valid phone number.
Child Protective Service Investigator Email
example@example.com
Agency CPI
Please Select
CPI (Texas)
CPI (Louisiana)
Current Investigation Notes
Agency FBSS
Please Select
FBSS (Texas)
FBSS (Louisiana)
Family Support Services Notes
Case Worker First Name
Case Worker Last Name
Case Worker Office Phone
Please enter a valid phone number.
Case Worker Cell Phone
Please enter a valid phone number.
Case Worker Email
example@example.com
Supervisor First Name
Supervisor Last Name
Supervisor Office Phone
Please enter a valid phone number.
Supervisor Cell Phone
Please enter a valid phone number.
Supervisor Email
example@example.com
State Conservatorship/Foster Care Agency
Please Select
Saint Francis
2Ingage
OCOK
Belong
EMPOWER
4Kids4Families
Family Care Network
Child's County of Origin
State Conservatorship/ Foster Care Notes
State Agency
Please Select
DFPS
DCFS
Extended Foster Care Notes
Notes or additional comments regarding Child Protective Service history
Psychiatric History
Psychiatric History
Current Psychiatric Diagnoses
Current medications
Current suicidal ideation or intent?
If so, please explain
Past suicide attempts (Yes/No/specify #)
If Yes, please include most recent attempt date
Aggressive and/or Violent Behavior (Including homicidal ideation)
History of Psychiatric Hospitalizations
Triggers/Precautions (specific to suicidality, maladaptive behaviors, dissociation, aggression, etc.)
Drug History
Drug History
Current or recent drug use
Please Select
No
Yes
Drug history notes
Runaway History
Runaway History
# of Runaways
Victimization and Special Classification
Victimization and Special Classification
Types of Victimization
Adult Physical Assault
Adult Sexual Assault
Adult Sexually Abused/Assaulted as Child
Arson
Bullying (verbal, cyber, or physical)
Burglary
Child physical abuse or neglect
Child pornography
Child sexual abuse/assault
Cyber Crimes
Domestic and/or Family Violence
DUI/DWI incidents
Elder Abuse or Neglect
Gang Violence
Hate Crime: Racial
Hate Crime: Religious
Hate Crime: Gender
Hate Crime: Sexual Orientation
Hate Crime: Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Crime (e.g. Hit and Run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Theft
Other Victimization
Types of Victimization - Other
Please specify
Special Classifications
Deaf/Hard of Hearing
Homeless
Immigrants/Refugees/Asylum Seekers
LGBTQ
Veterans
Victims with Disabilities: Cognitive/Physical/Mental
Victims with Limited English Proficiency
Other Special Classification
Special Classifications - Other
Optional Additional Uploads
Upload a File
Drag and drop files here
Choose a file
ROIs, Assessments, etc.
Cancel
of
Program
Submit Referral
Should be Empty: